Citation Nr: 18157528 Decision Date: 12/12/18 Archive Date: 12/12/18 DOCKET NO. 16-63 567 DATE: December 12, 2018 REMANDED Entitlement to service connection for a cervical trapezius disability, claimed as muscle tension, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD, is remanded. REASONS FOR REMAND 1. Entitlement to service connection for a cervical trapezius disability, claimed as muscle tension, to include as secondary to service-connected PTSD 2. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD A May 2012 VA treatment record indicates that there may be outstanding and relevant Social Security Administration (SSA) records. A remand is required to allow VA to request these records in order to determine if they are pertinent to the instant appeal. Additionally, in August 2017, the Board remanded the Veteran's claims to schedule a VA examination to determine the etiologies of the claimed disabilities. In a March 20, 2018, VA medical opinion, a VA psychiatrist, when asked if either of the claimed disabilties were either related to service or the Veteran's service-connected PTSD, wrote that the “condition claimed was at least as likely as not … incurred in” service because the Veteran was already “50% [service connected] for PTSD.” The Board notes that this opinion does not explain which condition the examiner believes is related to service. Moreover, in the basis for the opinion, the examiner does not explain how the Veteran’s PTSD effected either of the claimed disabilities. A remand is necessary to obtain clarification. The matters are REMANDED for the following action: 1. Obtain the Veteran’s federal records from SSA. Document all requests for information as well as all responses in the claims file. 2. Return the claims file to the VA psychiatrist who authored the March 20, 2018, medical opinion. If that examiner is unavailable or unwilling to provide an opinion, provide the claims file to an equally qualified examiner. After a review of the claims file, the examiner is asked to clarify the final opinion in their report, finding that a condition (presumably either the claimed hypertension or cervical trapezius disability) was related to service, because the Veteran was already 50 percent service connected for PTSD. The examiner specifically is asked to clarify which condition she believed was   related to service and how the Veteran’s PTSD effected that condition. A complete rationale supporting the opinion would be most helpful. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T.M. Gillett, Counsel