Citation Nr: 21062247 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 13-31 384A DATE: October 6, 2021 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a skin disability is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1981 to June 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2010 rating decision by the Department of Veterans Affairs (VA). This case was remanded in May 2019 for further development. In January 2019, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge; a transcript of that hearing is of record. 1. Entitlement to service connection for hypertension. The Board remanded this matter to determine whether there was a relationship between the Veteran's hypertension and his service-connected posttraumatic stress disorder (PTSD). The Board discussed that VA treatment records reflected potentially that the Veteran was non-compliant with his hypertension medication due to his PTSD symptoms. The Veteran underwent a VA examination in November 2020, wherein the examiner opined it was less likely than not that the Veteran's service-connected posttraumatic stress disorder (PTSD) aggravated his hypertension. However, as a rationale, the examiner only stated that there was no evidence in service of hypertension. An addendum opinion was obtained, wherein the same examiner stated that the Veteran's medications, including Prazosin, were not related to hypertension, while also simultaneously stated that Prazosin is an alpha blocker which can be used to lower blood pressure. There was no discussion of potential non-compliance. See December 2020 VA medical opinion. Finally, another addendum opinion was obtained in January 2021, wherein the same examiner simply stated that there was no medical rationale to establish a relationship between PTSD and hypertension, without rectifying his opinion with a Federal Register statement discussing that veterans with PTSD have a high risk of cardiovascular disease. All three opinions are inadequate because the examiner did not discuss the facts of the Veteran's case, such as non-compliance with medication, and do not discuss the Federal Register statement in the rationale as requested by the Board in its remand. As a result, remand for a new opinion is necessary. 2. Entitlement to service connection for a skin disability. The appeal period for this matter dates back to July 2009. See July 2009 claim. The Veteran underwent a VA examination in November 2020, wherein the examiner stated that there were no current symptoms and thus the Veteran did not have a current skin disability. The examiner also discussed that there was no evidence of hyperpigmentation in service. This opinion is inadequate because the Veteran need only have a disability at some point during the appeal period, and it is unclear whether the examiner was stating that the Veteran has not had a skin disability at all since July 2009. Moreover, new VA treatment records reflect diagnoses of acne, acne scarring, and mottled hyperpigmentation. See September 2017 and November 2017 VA treatment records. As a result, remand for a new examination is necessary. The matters are REMANDED for the following action: 1. The AOJ should obtain copies of VA treatment records from May 2021 to the present. 2. After the above development is completed, the AOJ should arrange for a VA medical opinion, with examination or telehealth interview of the Veteran only if deemed necessary by a medical professional, to determine the nature and likely cause of his hypertension. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record, the examiner should provide an opinion with detailed rationale that responds to the following: Is it at least as likely as not (50% or greater probability) that the Veteran's hypertension was either caused or aggravated by his service-connected PTSD, to include potential non-compliance with hypertension medication due to PTSD? Please explain why. The opinion must address whether the disability increased in severity beyond its natural progression (i.e., was aggravated). If aggravation is found, please identify to the extent possible the baseline level of disability prior to the aggravation. The examiner should discuss the Federal Register statement of June 28, 2007, 70 F.R. 37040 available in the claim file and address findings therein. 3. After the development in the first directive is completed, the AOJ should arrange for a VA examination of the Veteran to determine the nature and likely cause of any skin disability. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Please identify, by diagnosis, all skin disabilities present during the appeal period (from July 2009). The examiner must discuss whether the Veteran has had a skin disability at any time since July 2009, not just at the time of the examination. The December 2006 diagnoses of acne and acne keloidalis and September 2017 and November 2017 diagnoses of acne, acne scarring, and mottled hyperpigmentation should be discussed. If the examiner cannot provide an opinion without resorting to mere speculation, he or she must provide a complete explanation for why an opinion cannot be rendered; a rationale based on the fact that the Veteran is not demonstrating any symptoms at the time of the examination will not be deemed adequate. (b.) For each skin disability diagnosed, is it at least as likely as not (50% or greater probability) that the disability was either incurred in or otherwise related to the Veteran's active duty service, specifically due to sun exposure? Please explain why. The examiner must discuss that the Veteran began noticing a change in his skin after his second deployment. (c.) For each skin disability diagnosed, is it at least as likely as not (50% or greater probability) that the disability was either caused or aggravated by the Veteran's service-connected PTSD, specifically due to medication taken for PTSD? Please explain why. The opinion must address whether the disability increased in severity beyond its natural progression (i.e., was aggravated). If aggravation is found, please identify to the extent possible the baseline level of disability prior to the aggravation. The examiner may not rely solely on medical literature and must discuss the facts of the Veteran's case. 4. If upon completion of the above action the issues remain denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Sandler, 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.