Citation Nr: 21001986 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 15-44 796 DATE: January 12, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to PTSD and diabetes mellitus is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1969 to April 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was remanded in September 2018 and July 2020. Unfortunately, there has not been substantial compliance with the July 2020 remand instructions. 1. Entitlement to service connection for hypertension, to include as secondary to PTSD and diabetes mellitus is remanded. The Board cannot make a fully-informed decision on the claim because no VA examiner has opined whether the Veteran’s hypertension is related to exposure to herbicide agents in service, as was raised in the Veteran’s December 2015 VA Form 9. The National Academy of Sciences (NAS) Institute of Medicine’s Veterans and Agent Orange Update 2010 indicated limited or suggestive evidence of an association between herbicide agents and hypertension. See Determinations Concerning Illnesses Discussed in National Academy of Sciences Report: Veterans and Agent Orange: Update 2010, 77 Fed. Reg. 47,924, 47,926 (Aug. 10, 2012). Moreover, an August 2019 VA medical opinion found that the Veteran’s hypertension was less likely than not aggravated by service-connected PTSD, and stated as rationale that the Veteran has controlled blood pressure and has been diagnosed with diabetes and both conditions are known to go hand in hand. This statement is unclear but raises the possibility that the Veteran’s service-connected diabetes has caused or aggravated his hypertension. This theory of entitlement should also be addressed in a VA medical opinion. The July 2020 remand instructed the AOJ to obtain a medical opinion that considered whether the Veteran’s currently diagnosed hypertension was caused by or aggravated by (defined as any increase in disability) the Veteran’s service-connected PTSD. In doing so, the examiner was instructed to consider and discuss the VA material suggesting an association between PTSD and hypertension, with specific references to two VA regulations. The November 2020 VA medical opinion discussed several medical articles, but did not discuss the cited regulations. Moreover, the medical rationale provided was contradictory. At one point the clinician essentially noted that certain PTSD symptoms, namely fear-related symptoms, were linked to an increase in hypertension, and conceded that stress as one would experience with PTSD can cause issues with high blood pressure, but provided a negative aggravation opinion because the Veteran was diagnosed with hypertension before he was diagnosed with anxiety. The basis of that opinion is improper because under 38 C.F.R. § 3.310 (a), a primary disability need not be service-connected, or even diagnosed, at the time the secondary condition is incurred. Frost v. Shulkin, 29 Vet. App. 131 (2017). The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran’s hypertension. The clinician must provide the following opinions: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s hypertension is caused by exposure to herbicide agents during service? The clinician is advised that the Institute of Medicine found limited or suggestive evidence of an association between exposure to herbicide agents and hypertension. See Determinations Concerning Illnesses Discussed in National Academy of Sciences Report: Veterans and Agent Orange: Update 2010, 77 Fed. Reg. 47,924, 47,926 (Aug. 10, 2012) (b.) If the answer to the first question is negative, is it at least as likely as not (50 percent or greater probability) that the Veteran’s hypertension is proximately due to or aggravated (defined as any increase in disability) by the Veteran’s service-connected PTSD? The clinician should consider and discuss VA material suggesting 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). The clinician should also consider the November 2020 examination report noting that stress as one would experience with PTSD can cause issues with high blood pressure, with particular emphasis on fear-related symptoms. The mere fact that the Veteran was diagnosed with hypertension before he was diagnosed with anxiety is not sufficient grounds to find that the Veteran’s PTSD does not aggravate his hypertension. Moreover, the Veteran reported in his May 2013 Notice of Disagreement that he hid his psychiatric symptoms, which include remembering and dreaming of his fears of Vietnam, for years before he sought psychiatric treatment, which indicates that he suffered from the ill effects of PTSD for years before his formal diagnosis. (c.) If the answer to the first question is negative, is it at least as likely as not (50 percent or greater probability) that the Veteran’s hypertension is proximately due to or aggravated (defined as any increase in disability) by the Veteran’s service-connected diabetes mellitus? Each opinion must be supported by a complete rationale. 2. Confirm that the VA medical opinions provided comport with this remand, specifically that the standard for the secondary aggravation opinion 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 A. Budd, 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.