Citation Nr: 21068889 Decision Date: 11/15/21 Archive Date: 11/15/21 DOCKET NO. 15-22 499 DATE: November 15, 2021 ORDER New and material evidence has been received to reopen the claim for service connection for hypertension, and to that limited extent, the claim is granted. Service connection for hypertension is denied. REMANDED The claim for service connection for a heart condition, claimed as secondary to an acquired psychiatric disorder, to include as secondary to an acquired psychiatric disorder is remanded. The claim for service connection for a gastrointestinal disability is remanded. FINDINGS OF FACT 1. In an unappealed June 2003 rating decision, the RO denied connection for hypertension. 2. Evidence associated with the record received subsequent to the June 2003 rating decision is neither cumulative nor redundant of the evidence at the time of the June 2003 rating decision and raises a reasonable possibility of substantiating the claim of entitlement to service connection for hypertension. 3. The Veteran's hypertension did not have its onset in service, was not manifested within one year following service discharge, was not caused or aggravated by a service-connected disability, and is not otherwise related to service. CONCLUSIONS OF LAW 1. The June 2003 rating decision denying service connection for hypertension is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. Since the June 2003 rating decision, new and material evidence has been received with respect to the Veteran's claim of service connection for hypertension; therefore, the claim is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The criteria to establish service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from July 1966 to June 1972. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900 (c). This matter comes before the Board of Veterans' Appeals (Board) from a May 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The Veteran was afforded a Videoconference Hearing before the undersigned Veterans Law Judge in September 2018. A transcript of that hearing is of record. This matter was before the Board in April 2019. In that decision, the Board denied reopening of the Veteran's claims for service connection for an acquired psychiatric disorder and hypertension. The Board also denied service connection for a heart condition, gastrointestinal disability and a right knee disability. In April 2020, the Veteran appealed the Board's April 2019 decision to the United States Court of Appeals for Veterans Claims (CAVC), which vacated the Board decision and remanded it for compliance with a Joint Motion for Remand (JMR). See April 10, 2020 CAVC Order. In its August 2020 decision, the Board remanded the Veteran service connection claim for hypertension to obtain medical records from the Birmingham VAMC dating from 1974. The Board also remanded the Veteran's claims for service connection for an acquired psychiatric disorder, a right knee disability, a gastrointestinal disability, and a heart condition, claimed as secondary to an acquired psychiatric disorder, for the purpose of obtaining VA examinations and medical opinions. In a February 2021 rating decision, service connection for persistent depressive disorder (dysthymia) was granted. Service connection was also granted for a right knee disability. These are considered to be full grants of benefits sought. Therefore, these issues are no longer before the Board for appellate consideration. The claims of service connection for gastrointestinal disability, hypertension, heart condition, claimed as secondary to an acquired psychiatric disorder have returned to the Board for Appellate Review. The Board finds that further development is required with respect to the Veteran's gastrointestinal and heart condition claim. The Board finds that there has been substantial compliance regarding the Veteran's service connection claim for hypertension. New and Material Evidence In any case involving a finally denied claim, the Board must address whether new and material evidence has been received to reopen the claim before addressing the merits of the claim, regardless of whether or not the agency of original jurisdiction (AOJ) has already addressed the question. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001); Wakeford v. Brown, 8 Vet. App. 237, 239-40 (1995). The question of whether new and material evidence has been received to reopen such a claim must be addressed in the first instance by the Board, because the issue goes to the Board's jurisdiction to reach the underlying claim and adjudicate it on a de novo basis. See Jackson, 265 F.3d 1366; see also Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996), aff'g 8 Vet. App. 1 (1995). If the Board finds that new and material evidence has not been received, that is where the analysis must end; hence, what the RO may have determined in this regard is irrelevant. Jackson, 265 F.3d at 1369; Barnett, 83 F.3d at 1383. The Board has characterized the claims accordingly. New evidence is defined as existing evidence not previously submitted to VA, and material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied, but instead should include whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. Additionally, the United States Court of Appeals for the Federal Circuit has noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a claimant's injury or disability, even where it would not be enough to convince the Board to grant a claim. Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998). In a June 2003 rating decision, the RO denied the Veteran's claim for service connection for hypertension, finding no evidence that the Veteran's condition either was permanent or chronic in service, or manifested to a compensable degree within the applicable time limits. See June 18, 2003 Rating Decision. The Veteran was notified of the June 2003 rating decision and of his appellate rights; however, he did not submit a Notice of Disagreement (NOD). In general, rating decisions that are not timely appealed are final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. There was also no new and material evidence received within one year of the issuance of the decision. Therefore, the June 2003 rating decision is final. In September November 2011, the Veteran filed a petition to reopen his claim of entitlement to service connection for hypertension. See November 21, 2011 VA Form, 21-4138, Statement in Support of Claim. In a May 31, 2013 Rating Decision, the RO considered the claim reopened and confirmed the denial. See May 31, 2013 rating decision. Since the last prior denial, the RO has obtained VA records pursuant to the Board's August 2020 remand and provided the Veteran with a VA examination and medical opinions. In an August 2021 Supplemental Statement of the Case (SSOC), the RO reopened the claim and continued to deny the claim on its underlying merits. See August 8, 2021 SSOC. Despite the RO's determinations, in any case involving a finally denied claim, the Board must address whether new and material evidence has been received to reopen the claim before addressing the merits of the claim, regardless of whether or not the agency of original jurisdiction (AOJ) has already addressed the question. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). This claim claims have been characterized accordingly. The Board notes that evidence received since the June 2003 rating decision includes the November 21, 2011 Statement in Support of Claim, the Veteran's October 17, 2013 Notice of Disagreement (NOD), VA treatment records from the Birmingham VA Medical Center, the Veteran's December 2018 Board Hearing testimony, an April 15, 2021 VA Hypertension examination and Medical opinion (dated April 19, 2021), May 27, 2021 (dated May 31, 2021) Hypertension Medical Opinion, CAPRI records and an August 5, 2021 Hypertension Medical Opinion (Secondary Service Medical Opinion). The Board finds that that this evidence is new because it had not been previously submitted since the last prior final denial in June 2003. Second, the Board observes that the evidence is material because the VA Hypertension examination and medical opinions addresses whether the Veteran's hypertension was chronic or permanent during service. Additionally, the medical records from the Birmingham VA address the Veteran's treatment and diagnosis for his hypertension post-service. The medical records, VA examination and Medical Opinions, when considered in conjunction with the evidence already of record (e.g., service treatment records) addresses the underlying reason for the June 2003 rating decision denial. Hence, Board finds this evidence is material, as it raises a reasonable possibility of substantiating the claim for service connection for a hypertension. Accordingly, for the reasons stated above, the Veteran's previously denied claim for service connection for hypertension is reopened. 38 U.S.C. § 5108 38 C.F.R. § 3.156. To this limited extent only, the claim is granted. Service Connection In order to obtain service connection under 38 U.S.C. § 1110 and 38 C.F.R. § 3.303 (a) a Veteran must satisfy a three-element test: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so- called 'nexus' requirement. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Walker v. Shinseki, 708 F.3d 1331, 1333 (Fed. Cir. 2013). Service connection may also be granted on a presumptive basis for certain chronic diseases, including hypertension, if shown to be manifest to a degree of 10 percent or more within one year following a veteran's separation from active service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Additionally, service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show: (1) that a current disability exists and (2) that the current disability was either (a) proximately due to or the result of; or (b) aggravated (made worse) by a service-connected disability. 38 C.F.R. § 3.310 (b); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Veteran contends that his high blood pressure is related to service. During his September 2018 Board Hearing, the Veteran's representative asserted that the Veteran had four write-ups in service for high blood pressure, "and then, they would kind of bring him back in and do the check, and the blood pressure to within acceptable limits." The Veteran's representative also asserted that the Veteran's anxiety and depression that he experienced during service caused his hypertension. See Board Hearing transcript, pgs. 8-10. The Veteran has a current diagnosis of hypertension. See April 15, 2021 Hypertension examination, pg. 2. With regards to inservice complaints or treatment for hypertension the Board notes that in a January 1971 Periodic physical examination, the Veteran's blood pressure was 130/80. See January 26, 1971 Report of Medical Examination. The Veteran's blood pressure reading at his May 18, 1972 Separation examination was 118/90. In this May 1972 Separation examination, the Veteran denied any history of high or low blood pressure. The Veteran reported that his health was excellent. See May 18, 1972 Report of Medical History. See also, November 17, 1971 Report of Medical Examination, re: blood pressure normal on clinical evaluation (l20/80). Post-active duty records associated with service in the Air Force Reserve included a January 1975 examination report which showed a blood pressure reading of 138/88. See January 18, 1975 Report of Medical Examination. A January 25, 1976 Report of Medical History notes history of high blood pressure. The Veteran notes treatment at the VA in Birmingham. A December 9, 1978 Report of Medical examination reports that the Veteran's blood pressure was 130/90. This December 1978 Report of Medical examination reports that the Veteran was treated for elevated blood pressure. In this same examination, the Veteran stated that he had one episode of elevated blood pressure while in school in 1974. He was evaluated at the VA Hospital in Birmingham Hospital, but no medication was found to be required. On the December 1978 Report of Medical Examination, the Veteran's blood pressure was within normal limits. It was reported that the Veteran had never taken medication for blood pressure at that time. On a corresponding December 8, 1978 Reported of Medical History, the Veteran notes that he had been treated for high blood pressure. This December 1978 Report of Medical History (date stamped January 4, 1979) reports that the Veteran was treated for elevated blood pressure, not considered significant, not disqualifying. See December 8, 1978 Report of Medical History. The Board also notes the following post active-duty, non-service medical evidence: A February 6, 1975 treatment record shows the Veteran with a provisional diagnosis of mild hypertension. An October 27, 1976 treatment record notes that the Veteran was treated for hypertension. Progress notes dated January 4, 1977 reflect slightly elevated blood pressure readings: 126/96 (Supine); 120/100 (Sitting);130/100 (Standing). A treatment record noted the Veteran had been off medications for approximately two weeks. A May 1997 treatment record notes a diagnosis and treatment for hypertension. A February 19, 1998 medical record reports a diagnosis of and treatment for hypertension. January 14, 1999 Medical Records show that the Veteran's hypertension is fairly controlled. The medical record reports that the Veteran is to continue with medication compliance. The Veteran underwent a Hypertension examination in April 2021 to investigate the etiology of his hypertension. The April 2021 examiner acknowledged the Veteran's diagnosis of hypertension. However, after a review of the claims file and an examination of the Veteran, the examiner found it less likely than not that the Veteran's hypertension began in or was otherwise caused by the Veteran's active military service, reasoning that the Veteran did not have a chronic diagnosis for cardio/hypertension. Symptoms are subjective only. A nexus has not been established. See April 19, 2021 Medical Opinion, pgs. 1-2. An addendum medical opinion was sought in May 2021. The examiner noted review of the Veteran's claims folder, including, but not limited to the VA examinations of record, in-service treatment records, post-service treatment records and the Veteran's medical history. The 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 provided the following rationale to support this nexus opinion: The Veteran does have essential hypertension. This is documented in multiple records including the DBQ dated April 15, 2021, with an onset claimed in 1972. Records dated November 17, 1971 noted blood pressure of 120/80. January 1971 records had shown a blood pressure of 130/80. The separation exam is negative for hypertension and the Report of Medical History specifically notes no problems with blood pressure. Separation exams are notably thorough, and it is highly unlikely a significant hypertensive condition would have gone unnoted or unreported. A single blood pressure is reported as elevated at 130/90 in 1974 and a blood pressure of 138/88 is noted January 18, 1975, with "no treatment" documented. Records dated December 9, 1978 reflect a blood pressure of 130/90 with treatment. Therefore, it is less likely than not that the Veteran's blood pressure had its nexus in service. The Veteran developed elevated blood pressures post-service with documented treatment occurring in or around 1978. There is a 1976 record that reflects possible treatment as well. This does not alter the rationale. It is less likely than not that the Veteran's hypertension had its nexus in service or is due to events in service. Race and family history are the most likely meeting factors leading to hypertension. See May 31, 2021 Medical Opinion, pg. 2. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). The Board finds this May 2021 medical opinion probative for the following reasons: First, the examiner reviewed the Veteran's claims file, including the Veteran's service and post-service treatment records, his medical history and pertinent VA Hypertension examination. Second, the examiner provided a sufficiently detailed rationale for Board to make an informed decision as to the nature and etiology of this Veteran's hypertension disability. Third, the examiner provided a well-reasoned rationale for the conclusion reached, referencing pertinent evidence of record, with data points. Fourth, the examiner considered and addressed the favorable evidence of record, including the Veteran's elevated blood pressure reading during service and after service, before formulating a causal nexus opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). The Board also finds this May 2021 medical opinion, in conjunction with the April 2021 VA Hypertension examination adequate for adjudication purposes. The Board finds that this addendum medical opinion provides sufficient detail for the Board to make an informed decision on this Veteran's service connection claim. The Board has considered the Veteran's lay assertion that he had four write-ups in service for high blood pressure, and that when his blood pressure was checked, it would go back down to within acceptable levels. See Board Hearing testimony, pg. 8. The Board also takes note of the slightly elevated blood pressure reading during service in January 1971, 130/80. See January 26, 1971 Report of Medical Examination. The Board is also cognizant that the Veteran is competent to report on the observable symptoms of hypertension. The Board however assigns minimal probative value to the Veteran's assertion of a causal link between the Veteran's current disability and his active-duty service. To this point, the Board notes that the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the Board finds the Veteran's assertion of an etiological nexus between his current hypertension and service unpersuasive. The Board notes that the Veteran essentially acknowledged during his Board Hearing testimony that when his blood pressure was checked during service, it was within acceptable levels. See Board Hearing testimony, pg. 8. The Board underscores the May 2021 examiner noted that the Veteran's separation exam is negative for hypertension and the Report of Medical History specifically notes no problems with blood pressure. The examiner acknowledged that the Veteran developed elevated blood pressures post-service with documented treatment occurring in or around 1978. The examiner acknowledged that there is a 1976 record that reflects possible treatment as well. Notwithstanding, the May 2021 examiner concluded that it less likely than not that the Veteran's hypertension had its nexus in service or is due to events in service for the reasons he explained. Conversely, the May 2021 examiner attributed that Veteran's hypertension to other risk factors. See May 31, 2021 Medical Opinion, pg. 2. Because the examiner considered all of the lay and medical evidence of record, while providing a sufficiently detailed rationale for the Board to make an informed decision as to the etiology of the Veteran's currently diagnosed hypertension, the finds this May 2021 Addendum Medical Opinion, in conjunction with the April 2021 Hypertension examination probative and persuasive with respect to the nature and etiology of this Veteran's currently diagnosed hypertension. At the present time, there is no competent and probative evidence that outweighs the May 2021 VA medical opinion described in detail above. In summary, the Board finds that the Veteran's current diagnosed hypertension did not have its onset in service, was not manifested within one year following service discharge, and is not otherwise related to service. The Veteran has also asserted that his hypertension was caused or aggravated by his depression and anxiety. As referenced in the introduction of this decision, the Veteran is now service connected for a persistent depressive disorder (dysthymia). To address secondary service connection, a medical opinion was obtained in August 2021. The examiner noted review of relevant evidence, including but not limited to, VA examinations of record, in-service treatment records, periodic medical examinations post-service medical records and medical literature. However, he concluded that it is less likely than not that the Veteran's hypertension is due to or has been aggravated by his depression. The examiner provided the following rationale to support this etiological opinion: There is no anatomic or physiologic mechanism by which psychological conditions including depression (and PTSD or anxiety) can cause or aggravate hypertension. The current, widely accepted, peer-reviewed literature has not established depression and related psychological comorbidities as a cause of essential hypertension. By definition, essential hypertension is not caused by any other condition. This review includes Up-to-Date, a respected professional medical resource wherein one may access current professional treatises and studies. No articles were returned supporting a cause or aggravation link for psychological conditions and hypertension. The article cited above noted a possible association between depression but did not establish cause or aggravation. The authors merely concluded that further research with appropriately designed studies is required to determine the relationship between these conditions and hypertension. Though anxiety, stress, activity, panic attacks, a startling event, etc. may temporarily elevate one's blood pressure, this resolves following the abatement of the stimulus and the autonomic response ("Fight or flight/White coat HTN"). It does not constitute aggravation as it does not impact the baseline condition. Furthermore, there is no evidence of aggravation of the Veteran's hypertension beyond its natural course due to any cause. Changes in medication and/or dosages is common throughout the course of chronic hypertension and does not necessarily constitute aggravation. The average blood pressure on the 2021 DBQ was ~120/78. Therefore, it is less likely than not that the Veteran's hypertension is due to or has been aggravated beyond its natural course by the Veteran's depression and any related psychological comorbidities. See August 5, 2021 Medical Opinion. The Board finds this medical opinion probative. Here, the examiner first noted review of the pertinent lay and medical evidence of record. Second, the examiner provided a well-reasoned analysis for the conclusion reached. Third, the examiner's rationale is supported by a plausible medical explanation that takes into account the medical and lay evidence available as well as current medical literature regarding the Veteran's hypertension disability. Fourth, the examiner provided detail sufficient to allow the Board to make a fully informed determination on this Veteran's secondary service connection claim. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). The August 2021 examiner explained there is no anatomic or physiologic mechanism by which psychological conditions including depression (and PTSD or anxiety) can cause or aggravate hypertension. Referencing medical principles to support this conclusion, the examiner pointed out that by definition, essential hypertension is not caused by any other condition. Referencing medical literature to support this conclusion, the examiner noted that this review includes Up to Date. Continuing this discussion, the August 2021 examiner pointed out that although the medical literature does note a possible association between depression and hypertension, the medical literature does not establish cause or aggravation. Specifically discussing the pertinent evidence of record to illustrate the absence of aggravation (or any incremental increase in disability) for this Veteran, the examiner stated that the average blood pressure on the 2021 VA Hypertension examination was 120/78. The examiner pointed out that changes in medication and/or dosages is common throughout the course of chronic hypertension and does not necessarily constitute aggravation. See August 5, 2021 Medical Opinion. In this case, the Board assigns no probative value to the Veteran's assertion that his current hypertension is proximately caused or aggravated by his acquired psychiatric disorder. The Board finds that the Veteran does not possess the training or competence to render an etiological opinion on the causal link between hypertension and his service-connected persistent depressive disorder as such is a medically complex question. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). It follows that the Board finds the May 2021 medical opinion both probative and persuasive on the issue of causation and aggravation with respect to the Veteran's non-service-connected hypertension. In summary, the Board finds that finds that the Veteran's current hypertension did not have its onset in service, was not manifested within one year following service discharge, was not caused or aggravated by a service-connected disability and is not otherwise related to service. Accordingly, service connection is denied. REASONS FOR REMAND The Veteran has asserted that his heart condition is secondary to his acquired psychiatric disorder. During his September 2018 hearing, the Veteran testified that both his heart and GI symptoms may have been related to anxiety and depression during service. See Board Hearing transcript, pgs. 15-21, 33. The Veteran has been afforded Heart Conditions examination and Medical Opinion with regards to secondary service connection. The Veteran has been diagnosed with heart block. See April 19, 2021 Heart Conditions examination 1. See also, June 15, 2021, Medical Opinion (Heart Block), pgs. 2-3. While the examiner did address whether the Veteran's heart block was caused by the Veteran's acquired psychiatric disorder, there was no opinion offered regarding aggravation. The United States Court of Appeals for Veterans Claims (Court) has held that when an examiner determines whether service connection is warranted on a secondary basis, he or she must address both direct causation as well as aggravation. Allen v. Brown, 7 Vet. App. 439, 449 (1995). Therefore, on remand, an addendum opinion must be obtained. The Veteran has also asserted that his gastrointestinal disability is related to service. During his September 2018 Board Hearing, the Veteran testified that his gastrointestinal disability is related the reflux and vomiting he reportedly experienced therein. The Veteran also testified that both his heart and GI symptoms may have been related to anxiety and depression during service. See Board Hearing transcript, pgs. 15-21, 33. The Board notes that the Veteran has been afforded a VA examination and Medical Opinion to determine the nature and etiology of his gastrointestinal disability. In a January 2021 Esophageal conditions examination, the Veteran was diagnosed with GERD and Hernia hiatal. See January 29, 2021 Esophageal Conditions examination, pg. 2. The January 2021 VA examiner did provide what appears to be an adequate medical opinion with respect to direct service. However, the Veteran has also asserted that his gastrointestinal disabilities were related to his anxiety and depression. The Board notes that the Veteran is currently service connected for an acquired psychiatric disability (persistent depressive disorder). The Board finds that this theory of entitlement has been reasonably raised by the record and further development is required to afford the Veteran every opportunity to substantiate his service connection claim. Accordingly, these matters are REMANDED for the following action: 1. Obtain medical opinions with respect to the Veteran's heart block disability and gastrointestinal disability. If a physical examination is necessary to answer the Board's questions, one should be scheduled. The examiner(s) should answer the following questions: a) Is it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's claimed heart block was aggravated (made worse) by his acquired psychiatric disability? Why or why not? If aggravation is shown, the examiner should identify the baseline level of the heart disease by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the heart disease. b) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's gastrointestinal disability, to include GERD and hiatal hernia was caused by his acquired psychiatric disability? Why or why not? c) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's gastrointestinal disability, to include GERD and hiatal hernia was aggravated (made worse) by his acquired psychiatric disability? Why or why not? If aggravation is shown, the examiner should identify the baseline level of the gastrointestinal disease by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the gastrointestinal disability. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Little, 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.