Citation Nr: 1808278 Decision Date: 02/08/18 Archive Date: 02/20/18 DOCKET NO. 12-11 524A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for post-traumatic stress disorder (PTSD) with major depression. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for ischemic heart disease. 4. Entitlement to service connection for Peyronie's disease. 5. Entitlement to service connection for a left knee disability. 6. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and T.T. ATTORNEY FOR THE BOARD L.S. Kyle, Associate Counsel INTRODUCTION This matter was previously before the Board in June 2017. The Veteran appeared at a hearing before the undersigned in October 2017. The issues of entitlement to a higher initial rating for PTSD with major depression; entitlement to service connection for ischemic heart disease, Peyronie's disease, and a left knee disability; and entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT The Veteran's hypertension is proximately due to his service-connected PTSD with major depression. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310, 4.104, Diagnostic Code 7101 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted when a claimed disability is found to be proximately due to or the result of a service-connected disability, or when any increase in severity (aggravation) of a nonservice-connected disease or injury is found to be proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310. VA shall give the benefit of the doubt to the claimant when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Here, the record establishes the Veteran has hypertension. An April 2012 letter from the Veteran's treating physician, E.B., M.D., indicates the Veteran's systolic pressure measured between 180 and 190 for several months before the decision was made to treat the condition with prescription medication. See 38 C.F.R. § 4.104, Diagnostic Code 7101. The Veteran now requires continuous medication to control his hypertension. This has been confirmed by VA examiners. Thus, the Board finds the current disability requirement for the Veteran's service connection claim for hypertension has been met. In the April 2012 letter, E.B., M.D., indicated the Veteran's hypertension is the direct result of his service-connected PTSD with major depression because exacerbations of his psychiatric symptomatology coincide with increases in his blood pressure. In an October 2017 opinion, another physician involved in the Veteran's care, H.R., M.D., also reported the Veteran's hypertension is the direct result of his service-connected PTSD with major depression. H.R., M.D., explained the Veteran did not have hypertension prior to his active service. He further noted the initial elevated blood pressure readings in service were the result of a stress-related reaction, with the Veteran later been diagnosed as having PTSD. H.R., M.D., concluded these factors make it "quite clear" the Veteran's hypertension is the result of his service. These opinions are corroborated by two additional private opinions submitted by the Veteran, as well as medical literature that indicates PTSD is a major risk factor for developing hypertension. The Board finds this evidence is sufficient to establish the Veteran's hypertension is at least as likely as not proximately due to his service-connected PTSD with major depression. The Board acknowledges a February 2012 VA examiner determined the Veteran's hypertension was less likely than not the result of his service-connected PTSD with major depression; however, the Board finds the probative value of the February 2012 VA examiner's rationale is insufficient to overcome the weight of evidence that indicates the Veteran's hypertension is the result of service-connected PTSD with major depression. Thus, the Board finds the evidence is in at least relative equipoise as to whether the Veteran's hypertension is the result of service-connected PTSD with major depression. Resolving reasonable doubt in favor of the Veteran, the Board finds service connection for hypertension is warranted. ORDER Entitlement to service connection for hypertension is granted. REMAND Initially, the Board notes the Veteran's representative has reported there are outstanding VA treatment records that are relevant to the issues on appeal. VA's duty to assist requires efforts to ensure all available VA treatment records have been obtained and associated with the Veteran's claims file. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c); see also Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016). During the October 2017 hearing before the undersigned, the Veteran testified his service-connected PTSD with major depression has increased in severity since his most recent examination in September 2012. There is competent evidence to support this claim. Thus, the Board finds a new examination to assess the current severity of the Veteran's psychiatric disability is needed to make an informed decision on his claim. See Snuffer v Gober, 10 Vet. App. 400, 403 (1997) (holding the duty to assist requires VA to provide an examination when there is evidence of increased disability since the last examination). VA is required to provide an examination or obtain a medical opinion when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability; the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran has not been provided an examination for his service connection claim for a left knee disability even though the record indicates he has a left knee disability that may be associated with an in-service injury. The Board notes the record includes two notes from private physicians that suggest the Veteran's current left knee disability may be the result of an in-service injury on the deck of an aircraft carrier; however, these notes do not include sufficient rationale to establish the Veteran's service connection claim. Thus, a VA examination regarding the Veteran's service connection claim for a left knee disability is required to fulfill VA's to assist. There is also evidence that suggests the Veteran's current ischemic heart disease may be secondary to his newly service-connected hypertension. The Board finds a VA opinion is necessary in this regard. See El-Amin v. Shinseki, 26 Vet. App. 136, 138 (2013); Allen v. Brown, 7 Vet. App. 439 (1995). The issue of TDIU is inextricably intertwined with the other issues being remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) Accordingly, the case is REMANDED for the following action: 1. Obtain all outstanding VA treatment records and associate them with the claims file. 2. Schedule the Veteran for a new VA examination to assess the current severity of his service-connected PTSD with major depression. 3. Schedule the Veteran for a VA examination to obtain an opinion addressing whether his current left knee disability is at least as likely as not (50 percent probability or greater) the result of disease or injury in service. The examiner is advised the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide a reason for doing so. The examination report must include a complete rationale for the opinion provided. 4. Schedule the Veteran for a VA examination to obtain an opinion addressing whether his current ischemic heart disease is at least as likely as not (50 percent probability or greater) the result of disease or injury in service; or proximately due to, or aggravated by, his service-connected disabilities, to include, but not limited to, hypertension. The opinion must address both causation and aggravation to be deemed adequate. The examiner is advised aggravation means an increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation. The examination report must include a complete rationale for the opinion provided. 5. Readjudicate the issues on appeal. If any benefit sought on appeal remains denied, issue a supplemental statement of the case. Then, return the case to the Board, if otherwise in order. The Veteran 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. §§ 5109B, 7112 (2012). ______________________________________________ M. HYLAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs