Citation Nr: 21069526 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 17-52 744 DATE: November 18, 2021 REMANDED Entitlement to service connection for the Veteran's cause of death is remanded. REASONS FOR REMAND This matter was most recently before the Board of Veterans' Appeals (Board) in February 2021, when it was remanded so the Agency of Original Jurisdiction (AOJ) could obtain an opinion from an independent medical expert pursuant to 38 U.S.C. § 5109. Specifically, the Board directed the AOJ to obtain the opinion from a cardiologist and/or an internal medicine specialist outside the Veterans Health Administration (VHA). The selected expert was specifically asked to address the question: Was the hypertension, or any other cardiovascular disease, that led and/or contributed substantially or materially to the congestive heart failure that caused the Veteran's death at least as likely as not (50 percent probability or greater) proximately due to, or aggravated by, his service-connected post-traumatic stress disorder (PTSD)? This question was primarily based upon previous opinions provided by VHA physician, P.S.V., M.D., which note the "long-standing negative effects of hypertension on the heart leading to the subsequent development of congestive heart failure" in the Veteran's case. The Board's remand directives also instructed the selected expert to "address his or her qualifications to provide the requested opinion, to include a discussion of whether an expert in another specialty would be more well suited to address the question at hand" due to the complexity of the medical principles involved. Although it commends the AOJ's diligent efforts to obtain the requested opinion, the Board finds the record remains inadequate to ensure the decision on the Appellant's claim is fully informed. The record reflects the AOJ initially obtained an opinion from a non-VHA expert in internal medicine, G.M., M.D., in March 2021. After reviewing the initial report provided by G.M., M.D., the AOJ appropriately determined there was not substantial compliance with the Board's February 2021 remand directives because G.M., M.D., did not "address his or her qualifications to provide the requested opinion, to include a discussion of whether an expert in another specialty would be more well suited to address the question at hand." G.M., M.D., subsequently provided an addendum to his initial report, conceding a cardiologist would be better suited to provide the requested opinion. The AOJ then obtained a new opinion from a non-VHA cardiologist, P.M., M.D., in September 2021. Unfortunately, P.M., M.D., did not answer the specific question posed in the Board's February 2021 remand directives but rather three much broader questions explicitly listed in his report as: 1. Was the Veteran's Principle cause(s) of death End State Congestive Heart Failure or the Contributing Cause(s) of death none-natural death at least as likely as not (50 percent or greater probability) incurred in or caused by (the) n/a during service? 2. Is the Veteran's cause of death at least as likely as not (50 percent or greater probability) proximately due to or the result of post-traumatic stress disorder (formerly anxiety disorder under DC 9413)? 3. Was the Veteran's Veterans cause of death at least as likely as not aggravated beyond its natural progression by his/her service connected post-traumatic stress disorder (formerly anxiety disorder under DC 9413)? It is not clear why P.M., M.D., failed to address the specific question contained in the Board's February 2021 remand directives, although it appears he pulled the questions answered from the "Type of Medical Opinion Requested" section of the examination request rather than its more detailed instructions. Yet, the Board acknowledges, while not addressing the specific question posed in its February 2021 remand directives, P.M., M.D., explained the Veteran "did not have sufficient hypertensive heart disease to result in sufficient left ventricular hypertrophy (LVH) and reduced ejection fraction (EF) to produce congestive heart failure (CHF)." Nevertheless, the Board must reconcile this report with the other evidence of record, to include the opinions of P.S.V., M.D., which clearly note the "long-standing negative effects of hypertension on the heart leading to the subsequent development of congestive heart failure" in the Veteran's case. Further, it appears the September 2021 opinion from P.M., M.D., was based, at least in part, on an erroneous assumption that the Veteran was entitled to service connection for hypertension, when, in fact, the intent of the Board's remand directives was to obtain a secondary service connection aggravation opinion regarding hypertension in efforts to assist the Appellant in establishing a link in the chain between the Veteran's service-connected PTSD and the congestive heart failure that caused his death. Thus, an addendum to the September 2021 opinion is necessary to ensure the decision on the Appellant's claim is fully informed, as well as compliance with VA's duty to assist. The matter is REMANDED for the following action: Obtain an addendum to the September 2021 opinion provided by P.M., M.D., that explicitly answers the question: Was the hypertension, or any other cardiovascular disease, that led and/or contributed substantially or materially to the congestive heart failure that caused the Veteran's death at least as likely as not (50 percent probability or greater) proximately due to, or aggravated by, his service-connected post-traumatic stress disorder (PTSD)? The addendum must explicitly address both causation and aggravation to be deemed adequate. It must be noted aggravation means an increase in the severity of the underlying disability beyond its natural progression. In this context, P.M., M.D., must address the December 2019 written statement from the Veteran's son, M.S., M.D., that indicates "PTSD can directly damage the cardiovascular system through increases in blood pressure, impairment of vasodilation, formation of atherosclerotic plaques and heightened plaque instability" and how this medical principle applies in the facts present in the Veteran's individual case. P.M., M.D., is also asked to review the medical literature cited by M.S., M.D., and summarize how it either supports or weighs against a finding that PTSD either caused or aggravated hypertension, or cardiovascular disease, in the Veteran's case with specific emphasis on literature that discusses PTSD and risk of incident cardiovascular disease in aging veterans in light of his prior statements that hypertension is the most common risk factor for congestive heart failure with PTSD also being a risk factor for hypertension. It also asked that P.M., M.D., provide the secondary service connection opinion regarding hypertension even if he determines that hypertension was not a contributory cause of death in accordance with his prior suggestion that the Veteran "did not have sufficient hypertensive heart disease to result in sufficient left ventricular hypertrophy (LVH) and reduced ejection fraction (EF) to produce congestive heart failure (CHF)", as this statement will be weighed against the other evidence of record, to include the prior opinions provided by P.S.V., M.D., which note the "long-standing negative effects of hypertension on the heart leading to the subsequent development of congestive heart failure" in the Veteran's case. If P.M., M.D., is unavailable or cannot otherwise provide the requested addendum, it must be obtained from another non-VHA cardiologist. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. S. Kyle, 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.