Citation Nr: 19133167 Decision Date: 04/30/19 Archive Date: 04/29/19 DOCKET NO. 17-56 384 DATE: April 30, 2019 ORDER Entitlement to service connection for an acquired psychiatric disability, to include as secondary to service-connected low back, hearing loss, or tinnitus disabilities, is granted. REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for diabetes mellitus, type 2, to include as secondary to hypertension is remanded. Entitlement to a compensable initial rating for service-connected bilateral hearing loss is remanded. Entitlement to more than a 10 percent rating for service-connected tinnitus is remanded. FINDING OF FACT An April 2018 private psychiatric evaluation diagnosed the Veteran with depressive disorder with anxious distress and substance abuse features that the provider opined is permanently aggravated by his service-connected low back, hearing loss, and tinnitus disabilities, citing to medical research and literature indicating that (1) “[p]hysical symptoms are an integral component of co-occurring depression and anxiety disorders,” (2) tinnitus and hearing loss problems can be a “strong predictor” of mental illness in Veterans, that tinnitus sufferers “often gave reports of associated co-morbidities and many complained of impairment in lifestyle, emotional difficulties, sleep deprivation, migraine headaches, attention/concentration problems, hindrance with work and social life and an overall general decrease in mental health status,” (3) Veterans with tinnitus, hearing loss, and comorbid psychiatric problems often present with “non-tolerance to their auditory distortions/hearing problems which can drastically disrupt and interfere with their social, daily living and work life,” (4) “one-third of the veterans returning from the military will commonly suffer from psychiatric disorders, including major depression, most of which are related to concurring physical injuries and other medical conditions”, and (5) depression is by “far the most common emotion associated with chronic back pain” with high prevalence rates among patients with chronic low back pain. As this opinion is the only pertinent medical opinion of record, the Board finds the evidence is at least evenly balanced for and against (in “relative equipoise”) a finding that the Veteran has an acquired psychiatric disability related to his other service-connected disabilities. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disability, to include as secondary to service-connected low back disability, have been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303(b), 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The appellant is a Veteran who served on active duty from November 1981 to November 1985. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a February 2015 rating decision. For the reasons outlined above, the Board is granting service connection for an acquired psychiatric disability, obviating the need for any further discussion thereof at this time. The Board notes that the Veteran had originally perfected appeals of the effective dates assigned with awards of service connections for tinnitus and hearing loss. However, those issues are inherently part and parcel of the concurrent appeals challenging the initial ratings assigned for those disabilities, because they will require consideration of whether higher ratings are warranted at any time based on a substantive review of the entire record. Consequently, the Board has amended the issues on appeal for adjudicatory efficiency. REASONS FOR REMAND 1. Entitlement to service connection for hypertension is remanded. A review of the record shows the Veteran has a documented post-service diagnosis of hypertension as well as recorded blood pressures within the Stage 1 hypertensive range (based on the updated American Heart Association guidelines during service), including (but not limited to) readings of 140/90 (in January and June 1982), 110/80 (in November 1983), 114/80 (in October 1985), and 130/80 (on November 1985 separation examination). Therefore, a VA examination is needed to determine whether his current hypertension is related to the elevated blood pressures noted in service. 2. Entitlement to service connection for diabetes mellitus, type 2, to include as secondary to hypertension is remanded. In addition, the findings above regarding elevated and potentially already hypertensive blood pressure readings during service raise the question of whether, given the common association of diabetes and hypertension, this pathology could represent early indications or precursors of diabetic involvement as well. Moreover, there is also an open question as to whether the Veteran’s currently diagnosed diabetes could have a secondary relationship to hypertension. Therefore, an examination is needed to provide information that will allow the Board to obtain answers to these critical medical questions. 3. Entitlement to higher initial ratings for service-connected bilateral hearing loss and tinnitus are remanded. The Veteran has not been examined in conjunction with these claims since February 2015, over four years ago. As capturing a current disability picture is critical to an accurate rating of these disabilities, contemporaneous examinations are needed. The matters are REMANDED for the following action: 1. Obtain all updated records (i.e., those not already of record) of VA and adequately identified private treatment the Veteran has received for the disabilities remaining on appeal. 2. Schedule the Veteran for an examination by a cardiologist or other appropriate clinician to determine the cause of his hypertension. Based on a review of the record, examination of the Veteran, and any tests or studies deemed necessary, the examiner must opine as to whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that the Veteran’s hypertension is related to his military service, to specifically include the notations of elevated blood pressures therein. In so finding, the examiner MUST SPECIFICALLY CONSIDER AND DISCUSS the significance of blood pressure readings during service that already fell within the Stage 1 hypertensive range under the American Heart Association’s updated guidelines, to include (but not limited to) readings of 140/90 (in January and June 1982), 110/80 (in November 1983), 114/80 (in October 1985), and 130/80 (on November 1985 separation examination). All opinions must include a detailed explanation (rationale). (By law, the Board may not rely on any conclusion that is unsupported by a thorough explanation. Providing such an opinion or conclusion will delay processing of the claim and may require further clarification). 3. Schedule the Veteran for an examination by an endocrinologist or other appropriate clinician to determine the nature and cause of his documented diabetes mellitus. Based on a review of the record, examination of the Veteran, and any tests or studies deemed necessary, the examiner must opine as to whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that: (a.) his diabetes is related to the Veteran’s military service, to include consideration of whether the notations of elevated blood pressures (already within the Stage 1 hypertensive range according to the American Heart Association’s updated guidelines) therein might represent early indications or precursors of diabetic onset or involvement. (b.) his diabetes is otherwise CAUSED OR AGGRAVATED (“aggravation” in this context means WORSENED BEYOND ITS NATURAL PROGRESSION) BY his currently diagnosed hypertension. All opinions must include a detailed explanation (rationale). (By law, the Board may not rely on any conclusion that is unsupported by a thorough explanation. Providing such an opinion or conclusion will delay processing of the claim and may require further clarification). 4. Then, arrange for the Veteran to be examined by an audiologist to determine the current severity of his service-connected hearing loss and tinnitus. Based on an examination, review of the record, and any tests or studies deemed necessary (TO SPECIFICALLY INCLUDE audiometric tests), the examiner should describe all pathology, symptoms (frequency and severity), and functional impairment associated with such disabilities in sufficient detail to allow for application of the pertinent rating criteria. It is of critical importance that the examiner describe the functional impact associated with these disabilities, (particularly tinnitus) in detail. To that end, the examiner should not only refer to objective evidence but also elicit from the Veteran comprehensive subjective reports describing such impairment and the impact these disabilities have on his functioning. The inability to directly observe this impairment is not a valid reason, per se, to neglect this area of inquiry or evaluation. (CONTINUED ON NEXT PAGE) All opinions must include a detailed explanation (rationale). (By law, the Board may not rely on any conclusion that is unsupported by a thorough explanation. Providing such an opinion or conclusion will delay processing of the claim and may also require further clarification). VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Yuan, Associate Counsel