Citation Nr: 20021588 Decision Date: 03/26/20 Archive Date: 03/26/20 DOCKET NO. 17-25 594 DATE: March 26, 2020 REMANDED Entitlement to service connection for hypertension, to include as due to herbicide exposure and as secondary to posttraumatic stress disorder (PTSD), is remanded. Entitlement to special monthly compensation based on housebound status or the need for aid and attendance is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1968 to July 1971. This matter is on appeal before the Board of Veterans Appeals (Board) from June 2016 and January 2017 decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In a November 2018 decision, the Board, in pertinent part, denied the claims for service connection for hypertension and entitlement to special monthly compensation. The Veteran appealed. In a subsequent October 2019 decision, the Court of Appeals for Veterans Claims (Court) vacated the November 2018 decision and remanded the claims back to the Board for readjudication consistent with the decision. Service connection for hypertension, to include as due to herbicide exposure and as secondary to PTSD, is remanded. Special monthly compensation based on housebound status or the need for aid and attendance is remanded. In the October 2019 decision, the Court noted that in support of the claim for service connection for hypertension, the Veteran had submitted an opinion from a psychiatrist, Dr. J, from August 2015 and a medical research article entitled “The Impact of Mood and Anxiety Disorders on Incident Hypertension at One Year.” In the August 2015 opinion, Dr. J noted that several studies found an association between PTSD and poor cardiovascular health; PTSD was consistently associated with a greater likeliness of cardiovascular morbidity; PTSD might worsen or could be one of the causes of an elevation in blood pressure; and a lot of people who were diagnosed with PTSD operate in the fight or flight mode, which increases the adrenaline response, which also might cause an elevation in blood pressure. Dr. J concluded that as a result, it was as likely as not that the Veteran’s PTSD aggravates his hypertension. The Court also noted that there were VA medical opinions of record from a December 2016 VA examiner and a different May 2017 VA examiner. The December 2016 VA examiner found that the Veteran’s blood pressure presentation was not significant enough to determine that hypertension is aggravated beyond what would be expected with the natural progression of the condition. The May 2017 examiner opined that it was less likely than not that the Veteran’s hypertension was proximately due to or the result of his PTSD. The examiner agreed with Dr. J’s statement that there was often an increase in blood pressure when someone was chronically under stress; however, the research indicated that any spike in blood pressure is transitory and does not cause permanent damage, especially when one is on medication. The examiner additionally noted that the Veteran’s blood pressure was well-controlled on medication and had not been aggravated beyond its natural progression. The Court indicated that in denying the claim for hypertension, the Board found the VA examiners’ opinions more probative. Specifically, the Board found that Dr. J’s rationale was too general and his use of phrases such as “might worsen” discussed only a potential relationship between the PTSD and hypertension. The Court concluded that the Board provided inadequate reasons and bases for favoring the opinions of the VA examiners. The Court noted that even if Dr. J’s rationale contained speculative terms, the crux of the rationale, that individuals under stress often demonstrate increased blood pressure was endorsed by the May 2017 VA examiner. Also, the Board failed to address a serious deficiency in each VA opinion; that neither examiner explained the natural progression of hypertension or why they relied on the Veteran’s use of medication to inform their opinions. Additionally, the Board failed to address apparent inconsistencies in each VA opinion. In the December 2016 opinion, the examiner found that despite a 40-year history of PTSD, the Veteran was normotensive for 25 to 30 years following service. However, in a March 2009 rating decision awarding service connection for PTSD, the RO noted that the Veteran had given a history of psychiatric symptomatology since 2006 (i.e. a much shorter time than 25 to 30 years). In the May 2017 opinion, the examiner’s conclusion appeared to be based on research regarding temporary stress resulting in a transitory spike in blood pressure that normalized when the stress was removed. However, the Veteran’s PTSD is deemed to be a chronic condition as opposed to temporary stress. Given the inaccurate conclusion concerning the specificity of Dr. J’s rationale and the failure to address the apparent deficiencies and inconsistencies of the VA opinions, the Court found that the Board had provided inadequate reasons and bases for its denial of service connection for hypertension. The Court also found that the claim for SMC was inextricably intertwined with the claim for hypertension. Consequently, it vacated the Board’s denial concerning both issues and remanded these claims back to the Board for appropriate readjudication. Given the Court’s decision, the Board finds that a remand is required to obtain a VA medical opinion concerning the likely etiology of the Veteran’s hypertension. Also, given the Court’s finding that the SMC claim is inextricably intertwined with the claim for hypertension, it must also be remanded. Additionally, the evidence shows that the Veteran served in Vietnam from July 1969 to June 1970 and is presumed to have been exposed to herbicides. Although hypertension is not currently one of the diseases for which presumptive service connection may be awarded, in the most recent Veterans and Agent Orange: Update 11 (2018), the National Academies of Sciences, Engineering and Medicine (NAS) found sufficient evidence of an association for hypertension and exposure to Agent Orange and other herbicides used during the Vietnam War. Hypertension has been upgraded from its previous classification in the category of “limited or suggestive” evidence of an association to the category of “sufficient” evidence of an association. According to NAS, “[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. Given this change, a medical opinion is also needed concerning the likelihood that the Veteran’s current hypertension is related to his presumed herbicide exposure. On remand, such an opinion should be provided. The matters are REMANDED for the following action: 1. Obtain VA medical records of treatment or evaluation of the Veteran from April 2016 to the present. 2. Ask the Veteran to identify any records of non-VA treatment or evaluation he has received for hypertension or for psychiatric disability, which are not already of record. Obtain records of all treatment appropriately identified by the Veteran. 3. Schedule the Veteran for an examination by an appropriate physician to determine the nature and etiology of his current hypertension. The claims file must be reviewed in conjunction with the examination. This review should include any pertinent post-service medical records, including elevated blood pressure readings contained in VA treatment records as early as June 2011; the medical opinions from private psychiatrist, Dr. J, from August 2015 and October 2016; the December 2016 VA medical examination report with accompanying medical opinion; the medical research article entitled “The Impact of Mood and Anxiety Disorders on Incident Hypertension at One Year” received in February 2017; the May 2017 VA medical opinion; Agent Orange: Update 11 (2018) from the National Academies of Sciences, Engineering and Medicine (NAS) indicating that there is enough epidemiologic evidence to conclude that there is a positive association between hypertension and herbicide exposure; and any other information of record deemed pertinent. The examiner should then provide medical opinions in answer to the following questions: A) Is it at least as likely as not that the Veteran’s current hypertension is related to his herbicide exposure during service in Vietnam from July 1969 to June 1970? B) Is it at least as likely as not that the Veteran’s current hypertension has been aggravated by his service-connected PTSD? The examiner should explain the rationale for each opinion providing. Regarding opinion B, the examiner should be cognizant that the Veteran has reported that his psychiatric symptomatology began in approximately 2006. See e.g. March 2009 rating decision. Aggravation need not be permanent. 4. Based on the results of the VA examination with accompanying medical opinions, determine whether any further development is necessary for the Veteran’s claim for special monthly compensation based on housebound status or the need for aid and attendance, to include whether a VA examination is necessary. If so, conduct the further development. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Dan Brook, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.