Citation Nr: 21061993 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 09-03 649A DATE: October 6, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD), right knee degenerative joint disease, and lumbar spondylosis and sacralization, is remanded. REASONS FOR REMAND The Veteran had active duty service from August 1982 to November 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2007 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in April 2015. A transcript of that hearing has been associated with the claims file. In December 2015, the Board reopened the claim and remanded the case for further development. The Board also remanded case in July 2017, April 2019, and February 2021. The case has since been returned to the Board for appellate review. Upon review, the Board finds that additional development is needed prior to adjudication of the issue remaining on appeal. The Veteran was afforded a VA examination in February 2016 in connection with her claim for service connection for hypertension. The examiner opined that the Veteran's hypertension was less likely than not due to her service-connected PTSD. He stated that the cause of her hypertension was multi-factorial, and although her stress due to PTSD may be a contributing factor, it certainly was not the only factor. The examiner indicated that there were other risk factors, including pain, race, and the Veteran's exercise intolerance as a result of her back and knee conditions. The Veteran was afforded another VA examination in February 2020. The VA examiner opined that the Veteran's hypertension was controlled and not aggravated by her PTSD. The VA examiner also referred to the February 2016 VA examination report stating that the Veteran's hypertension was multi-factorial and noted that the PTSD maybe a contributing factor, as well as was her exercise intolerance due to her knee and back disorders. Nevertheless, in the most recent remand, the Board noted that the evidence of record did not include a medical opinion specifically addressing whether the Veteran's service-connected right knee and low back disabilities have caused or aggravated her current hypertension. Given the statements from the VA examiners indicating that she has exercise intolerance due to those disabilities and the fact that service connection had since been granted for a low back disorder, the Board found that an additional theory of entitlement had been raised that required a medical opinion. Thereafter, an additional VA medical opinion was obtained in February 2021. The examiner opined that it is less likely than not that the Veteran has hypertension that is causally or etiologically related to her military service. In rendering the opinion, she noted that all of the blood pressure readings obtained in the service treatment records were within normal range and that there was no evidence of hypertension in service or within one year thereafter. Rather, the Veteran was diagnosed with hypertension many years after service. The examiner also commented that the disorder was most likely multi-factorial with a substantial, strong genetic predisposition, and she noted other risk factors, including a family history of the disorder, age, obesity, diet, and lifestyle. She further cited to medical literature. In addition, the February 2021 VA examiner opined that it is less likely than that any current hypertension is caused by the Veteran's service-connected PTSD, right knee degenerative joint disease, and lumbar spondylosis and sacralization with radiculopathy, including any exercise intolerance resulting from those disabilities. She stated that hypertension is not caused by any other diagnosis or disease and that the preponderance of well-established scientific and evidence-based medical literature does not support a finding that primary (benign essential) hypertension is caused by PTSD, right knee degenerative joint disease, and lumbar spondylosis and sacralization with radiculopathy, including any exercise intolerance resulting from those disabilities. The February 2021 VA examiner further opined that it is less likely than not that any current hypertension is caused by the Veteran's service-connected PTSD, right knee degenerative joint disease, and lumbar spondylosis and sacralization with radiculopathy, including any exercise intolerance resulting from those disabilities. She found that there was no documentation of aggravation beyond the expected natural progression and found that her hypertension was well controlled. In addition, the February 2021 VA examiner opined that it is less likely than not that the Veteran's service-connected disabilities caused her to gain weight or become obese. Rather, she stated that the Veteran's weight gain and obesity is most likely due to genetic predisposition, as is her hypertension. Nevertheless, the February 2021 VA examiner did not address or reconcile her opinion with the fact that the February 2016 and February 2020 VA examiners both indicated that the cause of the Veteran's hypertension was multi-factorial and that the stress from her PTSD may be a contributing factor, as well as her exercise intolerance as a result of her back and knee conditions. Indeed, in addressing the Veteran's weight gain, the February 2021 VA examiner did not discuss her ability to exercise or any impairment limiting her exercise as a result of her service-connected disabilities. Therefore, the Board finds that an additional VA medical opinion is needed. Accordingly, the case is REMANDED for the following action: 1. The agency of original jurisdiction (AOJ) should refer the Veteran's claims file to a VA examiner for a medical opinion as to the nature and etiology of her hypertension. A physical examination is only needed if deemed necessary by the VA examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to matters of which she has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should provide an opinion as to whether it is at least as likely as not that any current hypertension is either caused by or aggravated by the Veteran's service-connected PTSD, right knee degenerative joint disease, and lumbar spondylosis and sacralization, including any exercise intolerance resulting from those disabilities. In rendering his or her opinion, the examiner should address both the causation and aggravation questions in his or her rationale. In other words, even if the Veteran's service-connected disabilities did not cause her current hypertension, the examiner should still address whether those disabilities could have worsened her hypertension. In addition, the examiner should state whether it is at least as likely as not that the Veteran's service-connected disabilities, to include any resulting impairment impacting her ability to exercise, caused her to gain weight or become obese. If so, the examiner should provide an opinion as to whether the weight gain or obesity was a substantial factor in causing the Veteran's hypertension. He or she should also provide an opinion as to whether the Veteran's hypertension would not have occurred or worsened but for the weight gain caused by her service-connected disabilities. In rendering this opinion, the examiner should specifically consider the February 2016 and February 2020 VA examination reports, which indicated that the cause of the Veteran's hypertension was multi-factorial, that the stress from her PTSD may be a contributing factor, and that "exercise intolerance" as a result of her back and knee conditions was a potential factor. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1, copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 2. After completing these actions, the AOJ should conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Rideout-Davidson, 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.