Citation Nr: 20060320 Decision Date: 09/14/20 Archive Date: 09/14/20 DOCKET NO. 13-03 676 DATE: September 14, 2020 REMANDED Entitlement to service connection for diabetes mellitus, type II, is remanded. Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1972 to November 1975. The Veteran testified at a hearing before the undersigned Veterans Law Judge in February 2017. A transcript of the hearing has been associated with the claims file. The claims were most recently before the Board of Veterans’ Appeals (Board) in August 2019, when they were remanded for additional development. 1. Entitlement to service connection for diabetes mellitus, type II, is remanded. 2. Entitlement to service connection for hypertension is remanded. September 2019 VA medical opinions obtained after the most recent remand are not adequate and the claims must be remanded again. Stegall v. West, 11 Vet. App. 268 (1998). Despite noting the Board’s directive to consider specific information in providing the diabetes opinion, the opinion provider did not provide any comment or discussion, beyond listing the information. The negative opinion on direct service connection for hypertension is inadequate. because the examiner improperly relies upon a lack of evidence of a diagnosis of hypertension in service. Further, although the remand defined aggravation as any increase in disability, the examiner rendered opinions identifying the wrong standard, “beyond the natural progression.” As the medical opinions obtained regarding the etiology of the Veteran’s diabetes mellitus, type II, and hypertension are not adequate and do not comply with the prior Board remand, the claim must be remanded for adequate VA medical opinions. Stegall v. West, 11 Vet. App. 268 (1998). The addendum opinion obtained on remand must also consider the effect of the Veteran’s service-connected PTSD on his hypertension. VA has found that a presumption of service connection is warranted for hypertensive vascular disease for prisoners of war (POWs). This presumption is based on several medical studies indicating that veterans who have a long-term history of PTSD have a high risk of developing cardiovascular disease and myocardial infarction. See Presumptions of Service Connection for Diseases Associated with Service Involving Detention or Internment as a Prisoner of War, 70 Fed. Reg. 37040 (June 28, 2005); Presumptions of Service Connection for Diseases Associated with Service Involving Detention or Internment as a Prisoner of War, 69 Fed. Reg. 60083 (Oct. 7, 2004). Accordingly, an addendum opinion is necessary to consider this. On remand, attempts must be made to obtain and associate with the claims file VA treatment records regarding the Veteran dated since October 2019. See 38 C.F.R. § 3.159. The matters are REMANDED for the following action: 1. Take all appropriate action to obtain VA treatment records from October 2019 to the present. 2. Thereafter, obtain an opinion from an appropriate clinician regarding the likely etiology of the Veteran's diabetes mellitus, type II, and hypertension. Copies of all pertinent records must be made available to the examiner for review. Following review of the record, the clinician should address the following: (a) Is it at least as likely as not (50 percent probability or more) that the Veteran’s diabetes and/or hypertension began in service or are otherwise related to service, specifically considering the (i) the April 1975 fasting blood sugar reading of 124, (ii) service treatment records, to include reports of dizziness, (iii) Veteran's statements, and (iv) the Veteran’s internet article. (b) If the answer to (a) is no for either diabetes or hypertension, is it as least as likely as not diabetes or hypertension was (i) caused or (ii) aggravated by the Veteran’s service-connected disabilities (PTSD, gastroesophageal reflux disease (GERD), left, ankle disability, tinnitus, hemorrhoids and erectile dysfunction). Aggravation here is defined as any increase in disability. The examiner should consider and discuss as necessary an association between PTSD and hypertension. See Presumptions of Service Connection for Diseases Associated with Service Involving Detention or Internment as a Prisoner of War, 70 Fed. Reg. 37040 (June 28, 2005); Presumptions of Service Connection for Diseases Associated with Service Involving Detention or Internment as a Prisoner of War, 69 Fed. Reg. 60083 (Oct. 7, 2004). A complete rationale must be provided for all opinions. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge; the examiner's own expertise, or; whether additional facts are required and note what, if any, additional evidence would permit such an opinion to be made. 3. Confirm that the VA medical opinions provided comport with this remand, specifically that the standard for the secondary aggravation opinions is any increase in disability, not the standard of beyond the natural progression as noted on the examination form itself. If not, get an addendum. M.E. LARKIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Robert J. Burriesci, 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.