Citation Nr: 21068849 Decision Date: 11/15/21 Archive Date: 11/15/21 DOCKET NO. 14-41 040A DATE: November 15, 2021 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for erectile dysfunction is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1966 to June 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in August 2012 by a Department of Veterans Affairs (VA) Regional Office (RO). By way of background, the Board most recently remanded the issues on appeal for additional development in August 2021, and the requested addendum opinions were obtained in August 2021. As such, the directives have been substantially complied with and the matter is again properly before the Board. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). In August 2021, the Board also denied service connection for an eye disability and peripheral neuropathy of the bilateral upper and lower extremities. 38 C.F.R. § 20.1100. As such, those issues are no longer on appeal. The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in August 2018. A transcript of the hearing is of record. 1. Entitlement to service connection for hypertension and erectile dysfunction. VA obtained opinions concerning the etiology of both disabilities in August 2021. The examiner opined that neither disability was directly related to any reported in-service injury or disease, instead noting that both the Veteran's hypertension and erectile dysfunction were more likely related to other risk factors present in the current case, including obesity. In a subsequent October 2021 appellate brief, the Veteran's representative argued that while the Veteran's hypertension and erectile dysfunction may be due to his obesity, his obesity in turn is due to his service-connected posttraumatic stress disorder (PTSD). Obesity may act as an "intermediate step" between a service-connected disability and a current disability that may be service-connected on a secondary basis. VA Gen. Coun. Prec. 1-2017 (Jan. 6, 2017). When addressing the issue of proximate cause, three issues must be resolved: (1) whether the service-connected disability caused the obesity; (2) if so whether the obesity as a result of the service-connected disability was a substantial factor in causing the current disability; and, (3) whether the current disability would not have occurred but for the obesity caused by the service connected disability. Id. The Court of Appeals for Veterans Claims expanded the 2017 General Council Opinion to also require consideration of aggravation of obesity by a service-connected disability. Walsh v. Wilkie, 32 Vet. App. 300, 30607 (2020). In light of the October 2021 appellate brief, the Board finds that a remand is required for additional opinions concerning whether the Veteran's obesity was caused by his service-connected PTSD. Further, in the October 2021 appellate brief the representative additionally argued that the Veteran's disabilities were directly secondary to his PTSD. Therefore, a remand is also required for an opinion addressing whether either disability was directly caused or aggravated by his PTSD. 38 C.F.R. § 3.310. The matters are REMANDED for the following action: 1. Obtain a medical opinion concerning the etiology of the Veteran's claimed hypertension. The examiner should answer the following: a) Is it at least as likely as not (a fifty percent probability or greater) that the hypertension was caused by the service-connected PTSD? b) If not, is it at least as likely as not (a fifty percent probability or greater) that the hypertension was aggravated (worsened) by the PTSD? c) Is it at least as likely as not (a fifty percent probability or greater) that the Veteran's obesity was caused or aggravated by the service-connected PTSD? In answering (c), attention is invited to the October 2021 appellate brief which cited an article discussing the effects of PTSD on activity levels and a possible correlation between depression and weight gain (labelled "Appellate Brief" uploaded 10/20/21). d) If so, is it at least as likely as not (a fifty percent probability or greater) that the obesity, or the aggravation thereof, was a substantial factor in causing the Veteran's hypertension? e) If so, is it at least as likely as not (a fifty percent probability or greater) that BUT FOR the obesity, or aggravation thereof, the Veteran would not have been diagnosed with hypertension? A detailed rationale for the opinion must be provided. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. 2. Obtain a medical opinion concerning the etiology of the Veteran's claimed erectile dysfunction. The examiner should answer the following: a) Is it at least as likely as not (a fifty percent probability or greater) that the erectile dysfunction was caused by the service-connected PTSD? b) If not, is it at least as likely as not (a fifty percent probability or greater) that the erectile dysfunction was aggravated (worsened) by the PTSD? In answering (a) and (b), attention is invited to the October 2021 appellate brief which cited to a study discussing a correlation between PTSD and erectile dysfunction (labelled "Appellate Brief" uploaded 10/20/21). c) Is it at least as likely as not (a fifty percent probability or greater) that the Veteran's obesity was caused or aggravated by the service-connected PTSD? In answering (c), attention is invited to the October 2021 appellate brief which cited an article discussing the effects of PTSD on activity levels and a possible correlation between depression and weight gain (labelled "Appellate Brief" uploaded 10/20/21). d) If so, is it at least as likely as not (a fifty percent probability or greater) that the obesity, or the aggravation thereof, was a substantial factor in causing the Veteran's erectile dysfunction? e) If so, is it at least as likely as not (a fifty percent probability or greater) that BUT FOR the obesity, or aggravation thereof, the Veteran would not have been diagnosed with erectile dysfunction? A detailed rationale for the opinion must be provided. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Wendell, 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.