Citation Nr: 21071418 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 16-49 082 DATE: November 30, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD) is remanded. Entitlement to a rating in excess of 50 percent for PTSD is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from September 1986 to December 1986 from September 1987 to September 1991 and from October 1993 to March 1995. These matters are before the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision. In a September 2016 VA Form 9 the Veteran requested a Board hearing. In October 2021 the Veteran withdrew his hearing request. 1. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD In July 2014 correspondence, the Veteran contended that his hypertension may be secondary to his service-connected PTSD. However, a review of the record shows that such theory of entitlement has not been addressed. Accordingly, a medical opinion which considers whether the Veteran's hypertension was caused or aggravated by the Veteran's service-connected PTSD is necessary. 2. Entitlement to a rating in excess of 50 percent for PTSD The record reflects that the Veteran receives ongoing treatment for his service-connected PTSD. However, his VA treatment records have not been updated since September 2017. Accordingly, up to date VA records must be sought. Additionally, the record contains a private examination dated in March 2016. However, it appears that the first page of the examination report from Dr. B.B. is absent from the record. Accordingly, attempts to obtain the complete opinion must be made. See Medical Treatment Record - Non-Government Facility receipt date March 22, 2016. Lastly, the Veteran was last examined in January 2015. Accordingly, an up-to-date examination which considers the Veteran's lay statements as well as reviews the Veteran's ongoing treatment is necessary. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records (since September 2017), and associate them with the claims file. Request the Veteran identify any outstanding private medical records. Appropriate efforts must be made to obtain these records. All actions to obtain the requested records should be fully documented in the claims file. If they cannot be located or no such records exist, the Veteran and his representative should be so notified in writing. 2. Ask the Veteran to submit the entire March 2016 private medical opinion concerning his PTSD. 3. Arrange for the Veteran's record to be forwarded to an appropriate clinician for review and a medical advisory opinion addressing the etiology of the Veteran's hypertension to specifically address whether it was caused or aggravated by his service-connected PTSD. On review of the record, the clinician should provide opinions that respond to the following: (a.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran's hypertension was caused or aggravated by his service-connected PTSD? (b.) If it is found that the Veteran's hypertension was not caused or aggravated by his service-connected PTSD, identify the etiology considered more likely. The clinician must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. (continued next page) 4. Following the addition of up-to-date medical records, arrange for a psychiatric examination of the Veteran to assess the severity of his PTSD. The Veteran's record must be reviewed by the examiner in conjunction with the examination. The examiner should have available for review the criteria for rating mental disorders. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Staskowski, 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.