Citation Nr: 21068843 Decision Date: 11/15/21 Archive Date: 11/15/21 DOCKET NO. 13-02 407 DATE: November 15, 2021 REMANDED Service connection for hypertension, to include as secondary to posttraumatic stress disorder (PTSD) or as due to exposure to herbicide agents, is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1967 and July 1970. In a September 2020 decision, the Board of Veterans' Appeals (Board) denied service connection for hypertension. He then appealed to the Court of Appeals for Veterans Claims (Court), which granted a Joint Motion for Partial Remand (JMPR) in July 2021. Remand to the agency of original jurisdiction (AOJ) is now necessary for additional development consistent with the JMPR. The parties to the JMPR agree that the July 2012 VA medical opinion is inadequate for two reasons. First, the opinion is internally inconsistent. While the 2012 examiner concluded "there are no credible references in medical literature which support the finding that [hypertension] is caused by PTSD," the examiner also cited literature from the Mayo Clinic indicating that stress-related spikes in blood pressure may put someone at risk of developing long-term high blood pressure. JMPR at 2. Second, the 2012 examiner found no "temporal relationship" between the Veteran's PTSD and hypertension. However, the examiner failed to explain why such a relationship would be required to establish a nexus. See Horn v. Shinseki, 25 Vet. App. 231, 240-42 (2012) ( "an unexplained conclusory opinion is entitled to no weight in a service-connection context"). JMPR at 2. The parties to the JMPR also agree that the Board failed to consider whether the December 2016 VA addendum opinion is adequate in light of subsequent evidence. Specifically, the 2016 examiner found that a National Academy of Sciences (NAS) report, which indicated there was "limited or suggestive evidence of an association between herbicide exposure and hypertension," does not establish that hypertension is caused by herbicide agent exposure. However, NAS subsequently moved hypertension from the "limited or suggestive evidence" category to the "sufficient evidence" category in its 2018 update to the report. This indicates "there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and herbicide agent exposure. JMPR at 3. Finally, the Veteran asserts that the Board erred when it failed to obtain a medical opinion regarding the Presumptions of Service Connection for Diseases Associated with Service Involving Detention or Internment as a Prisoner of War, published by VA at 69 Fed. Reg. 60083, 60087 (Oct. 7, 2004) (Interim Final Rule amending 38 C.F.R. § 3.309(c)). The Secretary of VA does not concede error on this point. However, the JMPR instructs the Board to address this argument on remand. JMPR at 4. The Veteran elaborates on this argument in his July 2021 brief. He asserts that a 2003 VA study, which is cited in the rule above, "concluded that the increased risk of hypertension [in prisoners of war (POWs)] was related to PTSD, not POW status." Brief at 3. On remand, the AOJ must obtain an addendum medical opinion on the etiology of the Veteran's hypertension. The addendum must reflect consideration of the evidence and contentions discussed above. The Board by this remand makes no determination, expressed or implied, concerning the credibility of any statements on file. The matter is REMANDED for the following action: 1. Obtain an addendum opinion on the etiology of the Veteran's hypertension from an appropriate clinician. Schedule another in-person examination only if the examiner deems it necessary to render the requested opinion. After reviewing the claims file (including this remand), the examiner must address the following: 2. Is it at least as likely as not (50 percent or greater probability) that the Veteran's hypertension is etiologically related to herbicide agent exposure? 3. Is it at least as likely as not (50 percent or greater probability) that the Veteran's hypertension is proximately due to his service-connected PTSD? 4. Is it at least as likely as not (50 percent or greater probability) that the Veteran's hypertension is aggravated beyond its natural clinical course by his service-connected PTSD? The examiner must clearly consider and discuss the following evidence in the opinion: (1) the Mayo Clinic article cited in the July 2012 VA examiner's opinion ("Stress and High Blood Pressure: What's the Connection?"); (2) the 2018 NAS report ("Veterans and Agent Orange: Update 11"); and (3) the 2003 VA study cited in Presumptions of Service Connection for Diseases Associated with Service Involving Detention or Internment as a Prisoner of War, 69 Fed. Reg. 60083, 60087 (Oct. 7, 2004) (later published as "Risk of Selected Cardiovascular Diseases and Posttraumatic Stress Disorder among Former World War II Prisoners of War"). 5. Review the medical opinion above to ensure substantial compliance with the Board's directives. Take any necessary corrective action. 6. Readjudicate the Veteran's claim. If it remains denied, issue a supplemental statement of the case and allow the Veteran the opportunity to respond. Then return to the Board for further appellate review. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D.Z. Wall, Associate 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.