Citation Nr: 21002880 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 17-03 590 DATE: January 19, 2021 ORDER Service connection for major depressive disorder is granted. REMANDED Service connection for residuals of adrenal gland surgery and amyloidosis is remanded. Service connection for hypertension is remanded. Service connection for kidney failure is remanded. Service connection for a heart disability, to include ischemic heart disease, is remanded. Service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to special monthly compensation due to the need for aid and attendance and/or due to being housebound is remanded. FINDING OF FACT Major depressive disorder is related to active service. CONCLUSION OF LAW The criteria for entitlement to service connection for major depressive disorder are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from December 1968 to December 1971, which included service in the Republic of Vietnam, and he is presumed to have been exposed to herbicide agents. In September 2014, the Veteran filed a claim of service connection for PTSD. The United States Court of Appeals for Veterans Claims (Court) has held that the Board must broadly construe claims and in the context of psychiatric disorders must consider other diagnoses for service connection when the medical record so reflects. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Thus, the Board will consider entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder, hence the recharacterization of the issues hereinabove. The Veteran asserts that he has PTSD and/or major depressive disorder due to active service. The Board concludes that the Veteran has a current disability of major depressive disorder that began during active service and is related to service. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). In December 2014, the Veteran underwent a C&P examination. The examiner diagnosed major depressive disorder and found that he does not have PTSD. The examiner noted that the Veteran was brought up in a very close-knit family. He was deployed to Thailand and missed his family very much. His depressive period started at that time. Subsequently, he sought treatment everywhere from time to time. An adrenal tumor was removed in 2003. His wife died in 2005 and he remarried. He had prostatic cancer in 2010, which was treated and had cardiac failure that was found to be due to a valve problem which was replaced in 2014. The examiner stated that he remains anxious, has hearing deficits, periods of sadness, withdrawal, and a great degree of anxiety, thus he meets the criteria for major depressive disorder, recurrent, moderate. He was not in a war zone, but he does have significant anxiety, hearing impairment, significant health issues including heart problems, heart failure, and adrenal problem with adrenal gland being removed in 2003. He had a prostatic problem and was given radiation treatment through seeding in 2010. He continues to depend heavily on his wife. VA treatment records reflect a diagnosis of depression. At the Board hearing, the Veteran testified that he recalled feeling depressed while he was stationed overseas, and he experienced depression shortly after separation from service. 09/23/2020 Hearing Transcript at 10-13. While service treatment records do not reflect any complaints of or treatment for depression, in light of the Veteran’s lay assertions and the December 2014 examiner’s opinion based on an interview and examination of the Veteran, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current major depressive disorder is due to service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for major depressive disorder is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Veteran’s claim of service connection for PTSD is addressed in the Remand below. REASONS FOR REMAND Residuals of adrenal gland surgery and amyloidosis The Veteran asserts that he has residuals of adrenal gland surgery and amyloidosis due to exposure to herbicides. AL amyloidosis is a presumptive disability subject to the Agent Orange presumptive provisions. 38 C.F.R. § 3.309 (e). A March 2017 VA treatment record reflects an indication of renal failure with suspected amyloidosis. An April 2017 VA treatment record reflects that a definite diagnosis of amyloidosis has not been made. In May 2017, he had a bone marrow study to rule out amyloidosis. A June 2017 problem list reflects ‘hemodialysis-associated amyloidosis.’ 08/15/2017 CAPRI at 49, 77, 89, 117. There are VA treatment records on file dated through April 2, 2018 but such do not indicate whether he has amyloidosis. Updated VA treatment records must be associated with the claims folder. An opinion should be sought as to whether he has amyloidosis, and whether he has residuals of adrenal gland surgery due to herbicide exposure. Hypertension The National Academy of Sciences, Engineering, and Medicine (NAS) recently published updated information about the relationship between a person’s exposure to Agent Orange and subsequent development of hypertension. It upgraded the relationship between hypertension and Agent Orange exposure from “limited or suggestive” to “sufficient,” indicating that “there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. See National Academies of Sciences, Engineering, and Medicine 2018, Veterans and Agent Orange: Update 11 (2018) at 10, 487-498. Considering there is evidence of a current disability of hypertension and the NAS findings suggesting that there may be an association between hypertension and herbicide exposure, remand is required for a medical opinion. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). It is also noted that the Veteran experienced hypertensive emergency in April and May 2020 but there are no treatment records from this period; updated VA treatment records must be sought. Kidney failure The Veteran asserts that he has kidney failure due to his hypertension. An opinion should be sought. Heart disability The Veteran asserts that he has ischemic heart disease thus triggering the presumptive provisions due to exposure to herbicides. In July 2014, the Veteran underwent a C&P examination wherein the examiner concluded that the Veteran did not have ischemic heart disease, and that he has diastolic function. 07/07/2014 C&P Exam. The Veteran testified that ischemic heart disease was diagnosed in or about 2017, but VA treatment records on file do not reflect a diagnosis of ischemic heart disease. Updated VA treatment records should be obtained, and the Veteran should be afforded another examination to clarify whether he has ischemic heart disease. PTSD Per this decision, service connection has been established for major depressive disorder. The Veteran has claimed service connection for PTSD, but a diagnosis is not contained within the medical evidence of record. As there are outstanding VA treatment records, the Board will defer consideration of this issue. SMC The Veteran’s claim for SMC is inextricably intertwined with the kidney failure service connection issue in appellate status, as he is claiming SMC due to his kidney failure. 09/23/2020 Hearing Transcript at 14-15. When a determination on one issue could have a significant impact on the outcome of another issue, such issues are considered inextricably intertwined, and VA is required to decide those issues together. See Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following actions: 1. Associate updated VA treatment records for the period from August 12, 2017 to September 27, 2017, and from April 3, 2018. 2. With regard to the claim for residuals of adrenal gland surgery and amyloidosis, request that an appropriate qualified examiner review the claims folder and provide opinions as to the following: a) Clarify whether the Veteran has AL amyloidosis; b) Clarify whether the Veteran has residuals of adrenal gland surgery; c) Are any residuals of adrenal gland surgery at least as likely as not (50 percent or greater probability) related to an in-service injury, event, or disease, to include exposure to herbicides? The examiner must provide a comprehensive rationale for all opinions proffered, and consideration should be given to the lay and medical evidence of record. An examination should be scheduled if deemed necessary by the examiner. 3. With regard to the claim for hypertension, request that an appropriate qualified examiner review the claims folder and provide an opinion as to whether hypertension is at least as likely as not (50 percent or greater probability) related to an in-service injury, event, or disease, to include exposure to herbicides? In formulating the opinion, the physician should consider the recent change in status of hypertension in Veterans and Agent Orange. See National Academies of Sciences, Engineering, and Medicine 2018, Veterans and Agent Orange: Update 11 (2018) at 10, 487-498. The examiner must provide a comprehensive rationale for all opinions proffered, and consideration should be given to the lay and medical evidence of record. An examination should be scheduled if deemed necessary by the examiner. 4. Request that an examiner with appropriate expertise review the claims folder and respond to the following with regard to the Veteran’s claimed kidney failure: a) Is kidney failure at least as likely as not (50 percent or greater probability) caused by hypertension? b) Is kidney failure at least as likely as not (50 percent or greater probability) aggravated (i.e., worsened beyond the normal progression of the disease) by hypertension? If aggravation is found, the examiner must attempt to establish a baseline level of severity of the kidney failure prior to aggravation by hypertension. Please note, causation and aggravation are separate concepts and must be addressed independently. The examiner must provide a comprehensive rationale for all opinions proffered, and consideration should be given to the lay and medical evidence of record. An examination should be scheduled if deemed necessary by the examiner. 4. With regard to the claim for a heart disability, request that an appropriate qualified examiner review the claims folder and provide opinions as to the following: a) Clarify whether the Veteran has ischemic heart disease or coronary artery disease; Consideration should be given to the diagnoses of record. b) Is a heart disability at least as likely as not (50 percent or greater probability) related to an in-service injury, event, or disease, to include exposure to herbicides? The examiner must provide a comprehensive rationale for all opinions proffered, and consideration should be given to the lay and medical evidence of record. An examination should be scheduled if deemed necessary by the examiner. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.W. Kreindler, 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.