Citation Nr: 18100802 Decision Date: 04/20/18 Archive Date: 04/20/18 DOCKET NO. 14-31 324A DATE: April 20, 2018 ISSUES DECIDED: 0 ISSUES REMANDED: 4 REMANDED ISSUES 1. Entitlement to service connection for a respiratory disability, to include chronic obstructive pulmonary disease (COPD), hemophilus influenza pneumonia, and upper respiratory infection (URI) 2. Entitlement to service connection for hypertension, to include as secondary to ischemic heart disease and posttraumatic stress disorder. 3. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 4. Entitlement to an initial rating greater than 10 percent for ischemic heart disease. The Veteran had active service from March 1968 to January 1971 with service in the Republic of Vietnam. A remand is necessary to obtain updated VA and private treatment records and additional examinations to determine the current severity of the heart disability and to obtain opinions in the first instance or to resolve conflicting opinions regarding service connection issues. The matters are REMANDED for the following action: 1. Associate with the electronic claims file all VA treatment records from July 2014 to the present. 2. Send the Veteran a letter requesting that he complete and return an Authorization and Consent to Release Information form (VA Form 21-4142) for any additional private treatment records not previously submitted to VA, including from the Bellin Health Pulmonary Clinic in Green Bay, Wisconsin. The notice letter should also indicate to the Veteran that, in the alternative, he is free to submit the outpatient clinic records directly to VA. (He should be notified that the documents he submitted to VA in February 2018 noted only that the Veteran had received treatment from the Bellin Health Pulmonary Clinic, but did not include the actual records or a summary of findings.) 3. Schedule the Veteran for an appropriate examination of his claimed psychiatric disorder with a VA or VA-contracted psychiatrist or psychologist. The examiner is requested to review the electronic claims file and to indicate that such a review has been accomplished. The examiner is requested to obtain a complete history from the Veteran and conduct an examination, with any indicated diagnostic testing. After completing the following, the examiner is asked to provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that any currently diagnosed psychiatric disorder was incurred in or is otherwise attributable to the Veteran’s active service. In reaching the above opinion, the examiner is requested to consider (and reconcile to the extent necessary) the June 2012 and June 2014 diagnoses of PTSD by Vet Center counselors, the opinion of the VA psychologist in September 2011, and the Veteran’s lay reports of sleep problems, intrusive thoughts, and mood changes, including depression, not documented during the September 2011 VA examination. Should a diagnosis of PTSD be made, the examiner is asked to opine as to whether the stressors on which the diagnosis was based are related to his fear of hostile military or terrorist activity. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 4. Obtain a medical opinion from an appropriate medical professional on the Veteran’s hypertension claim. Following a complete review of the electronic claims file, the reviewing professional is requested to provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s hypertension disability had its clinical onset during service, or is attributable to any in-service disease, event, or injury. (An opinion is not required as to entitlement on a secondary basis, as this was addressed in the February 2013 VA examination report.) In providing this opinion, the examiner should indicate consideration of the 2006 conclusion of the National Academy of Sciences (NAS) that found “limited or suggestive evidence of an association” between herbicide exposure and hypertension (notwithstanding that VA has not added hypertension to the list of conditions under 38 C.F.R. § 3.309 for which presumptive service connection due to Agent Orange exposure is available). The medical professional must provide the underlying reasons for any opinion provided. The term “at least as likely as not” does not mean “within the realm of medical possibility.” Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. 5. Schedule the Veteran for a VA heart examination to determine the current severity of his ischemic heart disease. The examiner must review the electronic claims file in conjunction with the examination. All indicated tests should be performed and all findings should be reported in detail. 6. After the above is complete and conducting any other necessary development (including an additional VA respiratory examination based on the records received from the Bellin Health Pulmonary Clinic), readjudicate the Veteran’s claims. If a complete grant of benefits is not granted, issue a supplemental statement of the case (SSOC) to the Veteran and his representative. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. J. Houbeck, Counsel