Citation Nr: 21068086 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 18-15 490 DATE: November 9, 2021 REMANDED Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran has active service from October 1966 to January 1969. This case is before the Board of Veterans' Appeals (Board) from an April 2017 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran appeared before the undersigned Veterans' Law Judge at a March 2020 hearing. In May 2020, the Board remanded this claim to the RO for additional development. While a medical opinion was obtained, for the reasons set forth below, the examination and accompanying opinions are insufficient. Regrettably, the Board finds additional remand is required. Service Connection for Hypertension. The Veteran has claimed his hypertension is due to his Vietnam service, to include as secondary to his service-connected posttraumatic stress disorder. The Veteran recalls that he was initially diagnosed with hypertension in approximately 1977, and contends that he was symptomatic prior to that date (3/16/2020 Hearing Transcript, pg.4). Alternatively, the Board notes that the Veteran is a Vietnam Veteran with verified herbicide exposure (1/17/2020 VA Memo). The Veteran's records were reviewed in July 2020 with regard to the Veteran's contentions regarding hypertension (07/13/2020 C&P Exam). His 1977 diagnosis of hypertension was confirmed by the July 2020 examiner (07/13/2020 C&P Exam, pg. 2). The July 2020 examiner provided negative nexus opinions for service connection on a direct basis, to include as a result of herbicide exposure, and as proximately due to PTSD (07/13/2020 C&P Exam). Unfortunately, the rationale provided for the examiner's opinions do not address conflicting evidence of record, and with regard to direct service connection, relied on the absence of medical evidence in service. As such, the Board finds them inadequate, requiring additional remand for clarification. In support of the examiner's negative nexus opinion, the examiner acknowledged that recent studies have shown an association between hypertension and veterans assigned to the chemical corps who had a high exposure to herbicides, but emphasized that there was no association with veterans with other occupational specialties. Contrary to the examiner's conclusion with regard to herbicide exposure, the record includes a reference to the latest in a series of Congressionally mandated biennial reviews evidencing health problems that may be linked to herbicide exposure during the Vietnam War. Sufficient evidence of an association with hypertension was reportedly found. Veterans and Agent Orange: Update 11 (2018), https://www.nationalacademies.org/news/2018/11/vietnam-veterans-and-agent-orange-exposure-new-report . With regard to the Veteran's hypertension being proximately due to PTSD, the July 2020 examiner reference the Framinghan study. The examiner relied on the finding that that 90 percent of people 55 and over will develop hypertension eventually, concluding all Vietnam era veterans have a 90% chance of developing hypertension whether they were exposed to agent orange or not. Here, the Veteran was born in 1946, and diagnosed with hypertension in 1977. Therefore, he was diagnosed with hypertension before he was 55. The examiner did not address whether or to what extent this distinction of age impacts the applicability of the study to this claim. The July 2020 examiner also indicated a review of current medical literature and research shows no physiologic or biomechanical causal relationship between a mental health condition (PTSD) and a physiologic condition of hypertension. The examiner concluded while anxiety states can cause a temporary elevation in blood pressure, they do not cause or permanently aggravate primary or secondary hypertension. Contrary to the examiner's conclusion with regard to PTSD, the record includes references to two studies suggesting a relationship between PTSD and hypertension. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3141329/ and https://www.ncbi.nlm.nih.gov/pubmed/19064371 . As previously noted, the July 2020 examiner opined that the Veteran's hypertension was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner's rationale for the negative nexus opinion was that the Veteran was separated from service in 1969 and there is no evidence of any diagnosis of hypertension while on active duty or within one year of separation (07/13/2020 C&P Exam, pg. 2). Here, the examiner appeared to rely on the absence of treatment records in support of the negative nexus opinion. It is well settled that the medical examiner cannot rely on the absence of medical records corroborating that injury to conclude that there is no relationship between the Veteran's current disability and active service Dalton v. Nicholson, 21 Vet. App. 23, 40 (2007). The Board finds the medical opinion insufficient because the conclusion was not supported with an analysis that the Board can consider and weigh against contrary opinions or evidence of record. Stefl v. Nicholson, 21 Vet. App. at 124. The matters are REMANDED for the following action: Forward the claims file to the July 2020 examiner if available (if not available, to a comparably qualified and appropriate clinician) for an addendum opinion consistent with this remand. If the following cannot be addressed without an examination, an examination should be scheduled. The examiner should opine whether any existing hypertension is at least as likely as not (50 percent probability or more) related to an in-service injury, event, or disease, including specifically herbicide exposure. The examiner should provide an opinion as to whether the Veteran's hypertension is at least as likely as not (50 percent probability) proximately due to any service-connected disease or disorder, specifically including service-connected posttraumatic stress disorder. The examiner should address whether it is as likely as not (50 percent probability) that the Veteran's service-connected posttraumatic stress disorder, or any other service-connected disease or disorder, has aggravated his hypertension beyond its natural progression. If aggravation is found, the examiner should identify baseline level of disability prior to such aggravation. The examiner should reconcile any conflicting medical evidence of record to the extent possible, specifically including the medical literature referenced this remand suggesting a relationship between herbicide exposure and hypertension, and PTSD and hypertension. With regard to the July 2020 citation to the Framinghan study, and finding that 90 percent of people 55 and over will develop hypertension eventually, the examiner should address whether or to what extent this distinction of age impacts the applicability of the study to this claim as the Veteran was diagnosed with hypertension diagnosis prior to the age of 55. The examiner is reminded to provide all findings, along with a complete rationale for his or her opinion(s). The examiner is reminded to consider the Veteran's lay reports, and a reason must be provided if the Veteran's lay reports are rejected. Lay statements cannot be rejected solely due to a lack of medical documentation. If the absence of medical documentation is relevant, the relevance must be explained because the absence of evidence is not positive evidence of the existence or non-existence of an event. (Continued on the next page) If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and explain why this is so, (e.g., whether an opinion is beyond what any medical practitioner might be able to provide, based on the evidence of record and current medical knowledge). Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. A. Myers 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.