Citation Nr: 21065291 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 16-44 966 DATE: October 25, 2021 ORDER Service connection for hypertension as secondary to service-connected posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to a disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded. FINDING OF FACT The evidence is at least in equipoise as to whether the Veteran's hypertension is the result of his service-connected posttraumatic stress disorder (PTSD). CONCLUSION OF LAW The criteria for service connection for hypertension as secondary to service-connected posttraumatic stress disorder (PTSD) have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service in the Marine Corps from June 1969 to March 1971. These matters come before the Board of Veterans' Appeals (Board) on appeal of a June 2016 Department of Veterans Affairs (VA) Regional Office (RO) rating decision that, in pertinent part, denied entitlement to a disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) and an August 2016 rating decision that, in pertinent part, denied entitlement to service connection for hypertension. 1. Service connection for hypertension as secondary to service-connected posttraumatic stress disorder (PTSD). As reflected by his July 2021 Board hearing testimony the Veteran contends that his hypertension is either the result of, or aggravated by, his service-connected posttraumatic stress disorder (PTSD). To establish secondary service connection, a Veteran must provide evidence of (1) a current, non-service-connected disability, (2) a current service-connected disability, and (3) evidence that the non-service-connected disability is either (i) proximately due to or the result of a service-connected disability or (ii) aggravated (increased in severity) beyond its natural progression by a service-connected disability. 38 U.S.C. § 1110; Allen v. Brown, 7 Vet. App. 439, 446 (1995); 38 C.F.R. § 3.310. In evaluating a claim for disability benefits, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107. In July 2016 a VA examiner documented that the Veteran was diagnosed with hypertension in approximately 2013. The July 2016 VA examiner opined that the Veteran's hypertension was less likely than not caused by or aggravated by his PTSD. The examiner stated only that "PTSD does not specifically cause [hypertension]" and that [w]hether the [hypertension] is truly aggravated by the PTSD is truly unknown." The examiner also stated that the Veteran had other risk factors for hypertension. In May 2017 VA received an evaluation by a non-VA medical provider, Dr. L. Dr. L. opined that PTSD leading to anxiety is at least as likely as not a significant cause of the Veteran's hypertension. In support of this conclusion, Dr. L. stated as follows: "PTSD often leads to anxiety and both could give somewhat elevated blood pressures. This is certainly true for short-term spikes of high blood pressure, but over time can move to a chronic picture. While weight gain can increase a patient's risk for hypertension, it does not appear to be true in this case. No connection can be seen in looking at weights and blood pressure over time." In light of the foregoing, the Board finds that the evidence is at least in equipoise as to whether the Veteran's hypertension is the result of his service-connected PTSD. Resolving doubt in favor of the Veteran, the Board concludes that the criteria for entitlement to service connection for hypertension as secondary to PTSD are met, and the same is hereby granted. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS FOR REMAND Entitlement to a disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded. The Veteran filed a claim for a disability rating in excess of 30 percent for PTSD in July 2015. The effective date of an award of increased compensation shall be the earliest date as of which it is ascertainable that an increase in disability had occurred if application is received within one year from such date. Gaston v. Shinseki, 605 F.3d 979, 980 (Fed. Cir. 2010); 38 C.F.R. § 3.400(o)(2). Accordingly, the period on appeal is from July 2014 to the present. VA treatment records were last obtained and associated with the claims file in November 2016. The Veteran was last afforded a VA examination in July 2016. He has provided privately obtained evaluations of his PTSD, the most recent having been performed in January 2018. It is the responsibility of the Board to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. Features of the disability which must have persisted unchanged may be overlooked or a change for the better or worse may not be accurately appreciated or described. Accordingly, the Board finds that it is necessary to remand the Veteran's PTSD claim to obtain both updated VA treatment records. The Veteran should be afforded an opportunity to identify and/or provide any other pertinent mental health treatment records. After any such VA or non-VA treatment records are obtained and associated with the claims file, an updated VA examination should be obtained that addresses both the current severity of the Veteran's PTSD and its severity throughout the period on appeal in light of all available evidence. The matters are REMANDED for the following action: 1. Ask the Veteran to execute a VA form 21-4142 for all providers he has seen for his PTSD Obtain medical records from all providers identified by the Veteran in his executed VA Form 21-4142 and obtain all available VA treatment records November 2016. Ensure that all records obtained pursuant to this remand are associated with the claims file. 2. Following the completion of Remand Directive 1, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of the Veteran's PTSD. The examiner is also asked to opine as to the severity of the Veteran's PTSD throughout the period on appeal. The claims folder, including a copy of this remand, must be made available to the examiner and such review should be noted in the examination report. A complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resorting to speculation, it is essential that the examiner explain why an opinion cannot be provided and specifically state whether the inability to provide an opinion is due to the limits of the examiner's knowledge, the limits of medical knowledge in general, or there is additional evidence that would allow for an opinion on this matter. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Sametshaw, Eric C. 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.