Citation Nr: 1647561 Decision Date: 12/21/16 Archive Date: 12/30/16 DOCKET NO. 11-12 431 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to service-connected traumatic brain injury (TBI) with migraine headaches and posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for depression, to include as secondary to service-connected TBI with migraine headaches and PTSD. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. Hampton, Associate Counsel INTRODUCTION The Veteran served a period of honorable service from June 1979 to December 1982, and a period of dishonorable service from December 1982 to May 1985. This case comes before the Board of Veterans' Appeals (Board) on appeal of a March 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. Jurisdiction over the Veteran's claims was subsequently transferred to the RO in Atlanta, Georgia. When this case was before the Board in March 2015, it was remanded for additional development. The case is now again before the Board for further appellate action. The record before the Board consists of electronic records within Virtual VA and the Veterans Benefits Management System. FINDINGS OF FACT 1. The evidence is at least in equipoise as to whether the Veteran's currently diagnosed hypertension has been aggravated by her service-connected TBI with migraine headaches and PTSD. 2. The evidence is at least in equipoise as to whether the Veteran's currently diagnosed depression has been aggravated by her service-connected TBI with migraine headaches and PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension have been met. 38 U.S.C.A. §§ 1110, 5103A, 5107, 7104 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2016). 2. The criteria for service connection for depression have been met. 38 U.S.C.A. §§ 1110, 5103A, 5107, 7104 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist In this decision, the Board grants entitlement to service connection for hypertension and depression, which constitutes a complete grant of the Veteran's claims. Therefore, no discussion of VA's duties to notify or assist is necessary. Legal Criteria Service connection may be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2016). Establishing service connection on a secondary basis requires evidence showing that (1) a current disability exists and (2) the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc) (additional disability resulting from aggravation of a nonservice-connected disorder by a service-connected disorder is also compensable under 38 C.F.R. § 3.310). Given the favorable nature of the Board's decision on a secondary basis, the Board will not address a theory of direct service connection. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2016); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Background and Analysis The Board notes at the outset that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). To be considered adequate, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The record shows the Veteran has been diagnosed with hypertension and depression. The Veteran is service connected for a TBI with migraine headaches and PTSD, relating to a November 1981, in-service assault. The Veteran has contended her hypertension and depression were caused by or have been aggravated by her in-service TBI and residuals. In its March 2015 remand, the Board determined no adequate VA examinations addressing the Veteran's contentions had been provided. As such, the Board remanded the Veteran's claims for VA examinations. The VA examiners were instructed to opine as to whether the Veteran's hypertension and depression were etiologically related to her service or had been caused or aggravated by her service-connected TBI with migraine headaches and PTSD. The Veteran was subsequently afforded VA hypertension and psychiatric examinations in April 2015. Pursuant to her hypertension examination, the VA examiner diagnosed hypertension but opined the condition was less likely than not caused or aggravated by the Veteran's service or by any service-connected disability. In this regard, the examiner stated the Veteran's service treatment records (STRs), separation examination, and post-service medical records were negative for hypertension until 2013. The examiner further stated the Veteran's blood pressure was controlled with medication, that she had no renal insufficiency or kidney disease, and that chest X-rays were negative for cardio-pulmonary issues and her labs were unremarkable. Pursuant to her psychiatric examination, the examiner noted the Veteran had been diagnosed with PTSD and major depressive disorder, and indicated it was not possible to differentiate which of the Veteran's symptoms were attributable to each diagnosis because the symptoms "appeared to be comorbid." The examiner also noted the Veteran had been diagnosed with a TBI. In this regard, the examiner stated that as a psychologist, she was unable provide an opinion as to TBI-related symptoms because to do so would constitute operating outside of her scope of practice. She stated that any opinion about a TBI was best rendered by an expert examiner in that field, such as a psychiatrist or other physician. The record does not show any opinion by a psychiatrist or other physician was subsequently solicited by the RO. The Board first notes the VA hypertension examiner failed to provide any opinion directly addressing whether the Veteran's hypertension was related to her TBI residuals, as instructed by the Board. The examiner simply stated the Veteran's blood pressure was controlled by medication, and made irrelevant findings regarding renal insufficiency and kidney disease. In this regard, the Board notes the examiner's rationale did not address the possibility that although the Veteran's hypertension was medically controlled, such medication would not be necessary absent aggravation of the condition by the Veteran's service-connected TBI residuals. With regard to the Veteran's psychiatric examination, the Board notes the examiner's own admission that she was unqualified to respond to the Board's questions as to any potential effect of the Veteran's service-connected TBI residuals on her depression. For the foregoing reasons, the Board has determined the April 2015 VA examination reports are inadequate for adjudication purposes. As such, the Board affords these reports limited probative weight. Importantly, the Veteran submitted letters by VA healthcare providers in November 2014 addressing the etiology of her hypertension and depression. In the first letter, the Veteran's VA physician, Dr. T.T., stated that although there are many causes of hypertension, it was his opinion that it was at least as likely as not that the Veteran's service-connected migraine headaches had contributed to or aggravated her hypertension. In the second letter, a VA nurse practitioner at the Atlanta VA Medical Center (VAMC) Traumatic Brain Injury Clinic noted the Veteran had been diagnosed with a remote TBI relating to an in-service assault in 1981. The author stated the Veteran's TBI was emotionally damaging, as it was the result of a beating by fellow soldiers who should have been invested in her safety. The author noted the Veteran also had some reported traumatic childhood experiences, but stated it was very likely the Veteran's in-service beating and TBI exacerbated her depression. Upon a careful review of the foregoing and of the entire record, the Board finds the evidence supporting the Veteran's claims is at least in equipoise with the evidence weighing against the claims. In this regard, the Board again notes its finding that the VA examinations of record addressing the Veteran's contentions are unsupported by adequate rationales. Conversely, the Veteran's treating VA physician, in addition to a VA nurse practitioner specializing in traumatic brain injuries, have provided opinions stating the Veteran's hypertension and depression have more likely than not been aggravated by her service-connected TBI residuals. Because the Board has found the evidence to be in equipoise with respect to both claims, granting of both claims is warranted. ORDER Entitlement to service connection for hypertension is granted. Entitlement to service connection for depression is granted. ____________________________________________ KELLI A. KORDICH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs