Citation Nr: 21072106 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 13-22 915 DATE: December 2, 2021 ORDER Entitlement to service connection for hypertension is granted. Entitlement to service connection for coronary artery disease is granted. Entitlement to service connection for kidney failure is granted. REMANDED Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. Entitlement to service connection for obstructive sleep apnea is remanded. FINDINGS OF FACT 1. The Veteran's hypertension is secondary to service-connected depression. 2. The Veteran's coronary artery disease is secondary to service-connected depression and hypertension. 3. The Veteran's kidney failure is secondary to service-connected hypertension. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension have been met. See 38 U.S.C. § 1110; 38 C.F.R. § 3.310. 2. The criteria for service connection for coronary artery disease have been met. See 38 U.S.C. § 1110; 38 C.F.R. § 3.310. 3. The criteria for service connection for kidney failure have been met. See 38 U.S.C. § 1110; 38 C.F.R. § 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1968 to August 1972, including service at Camp Lejeune. This case comes to the Board of Veterans' Appeals (Board) from an August 2010 rating decision that denied service connection for coronary artery disease; a September 2014 rating decision that denied service connection for an esophageal disability and confirmed a prior final decision denying service connection for kidney failure; and an April 2015 rating that denied service connection for hypertension and obstructive sleep apnea. In May 2016, the Board remanded the claim for coronary artery disease for further development and remanded the other claims for issuance of a statement of the case. In January 2020, the Board remanded the claims for hypertension, kidney failure, an esophageal disability, and obstructive sleep apnea for further development. In July 2020, the Board found that new and material evidence had been received to reopen a prior final decision denying service connection for kidney failure. The Board then remanded this claim and the other claims for further development. A November 2020 rating decision granted service connection for depression. In a July 2021 letter, the Veteran's attorney requested 90 days to submit additional evidence. No additional evidence was submitted. SERVICE CONNECTION Service connection may be granted on a secondary basis for a current disability that is proximately due to or aggravated by a service-connected disease or injury. See 38 C.F.R. § 3.310. Service connection will be granted when the evidence supports the claim or is in relative equipoise. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Entitlement to service connection for hypertension is granted. The Veteran asserts that service connection is warranted for hypertension secondary to service-connected depression. An August 1968 entrance examination documented normal blood pressure and no abnormalities with the vascular system. Accordingly, the Board finds that the Veteran was in sound condition at entry to service. The Veteran's primary care physician, Dr. L.N.D., listed depression as a risk factor for hypertension. In March 2016, Dr. H.S. reviewed the Veteran's claims file and provided a medical opinion as to the etiology of the Veteran's hypertension. Dr. S. noted that a February 2016 psychological examination showed that the Veteran had near continuous panic or depression. Dr. S. opined that the Veteran's depression, which began during service, aided in the development of hypertension and that it was as likely as not that hypertension was permanently aggravated by depression. Dr. S. cited a medical study concluding that depression is predictive of later incidence of hypertension. At a March 2021 VA examination, Dr. L.G.D. diagnosed the Veteran with hypertension. Dr. D. opined that it was less likely than not that the Veteran's hypertension was proximately due to or aggravated by service-connected depression because hypertension is due to other factors, such as aging. Dr. D. also stated that the Veteran was diagnosed with essential hypertension, which indicated that there is no known cause. It is undisputed that the Veteran has a current disability of hypertension and is service connected for depression. Therefore, the relevant issue is whether this current disability is secondary to service-connected depression. The Board finds that the Veteran's current disability of hypertension is proximately due to service-connected depression. While Dr. S. opined that hypertension was permanently aggravated by depression, his opinion also indicates that this disability was caused by depression. The Board accords probative weight to Dr. S.'s opinion because it was based on a thorough review of the Veteran's claims file and consistent with medical literature. Moreover, Dr. S.'s opinion is consistent with Dr. L.N.D.'s treatment records listing depression as a risk factor for hypertension. The Board accords limited probative weight to Dr. L.G.D.'s opinion because she did not explain why depression is not related hypertension, and did not consider the medical study cited by Dr. S. or Dr. L.N.D.'s treatment records. In sum, when weighing the conflicting evidence, the Board finds that the probative evidence of record supports the Veteran's claim. See Gilbert, 1 Vet. App. at 55. Accordingly, the Board finds that service connection is warranted for a hypertension secondary to service-connected depression. See 38 C.F.R. § 3.310. Entitlement to service connection for coronary artery disease is granted. The Veteran asserts that service connection is warranted for coronary artery disease secondary to service-connected depression and hypertension. An August 1968 entrance examination documented no abnormalities with the heart. Accordingly, the Board finds that the Veteran was in sound condition at entry to service. The Veteran's VA cardiologist, Dr. W.F., listed hypertension as a risk factor for coronary artery disease. In March 2016, Dr. H.S. reviewed the Veteran's claims file and provided a medical opinion as to the etiology of the Veteran's coronary artery disease. Dr. S. opined that the Veteran's depression and hypertension aided in the development of coronary artery disease and that it was as likely as not that coronary artery disease was permanently aggravated by depression. Dr. S. cited a medical study concluding that depression is an independent risk factor for coronary artery disease and American Heart Association research showing that hypertension causes heart conditions, such as coronary artery disease. At a March 2021 VA examination, Dr. L.G.D. diagnosed the Veteran with coronary artery disease. Dr. D. opined that it was less likely than not that the Veteran's coronary artery disease was proximately due to or aggravated by service-connected depression because coronary artery disease is due to hyperlipidemia and tobacco abuse. Dr. D. also stated that the Veteran had a family history of heart disease and that depression is not a cause of coronary artery disease. It is undisputed that the Veteran has a current disability of coronary artery disease and is service connected for depression and, as a result of this decision, hypertension. Therefore, the relevant issue is whether this current disability is secondary to service-connected depression or hypertension. The Board finds that the Veteran's current disability of coronary artery disease is proximately due to service-connected depression and hypertension. While Dr. S. opined that coronary artery disease was permanently aggravated by depression, his opinion also indicates that this disability was caused by depression and hypertension. The Board accords probative weight to Dr. S.'s opinion because it was based on a thorough review of the Veteran's claims file and consistent with medical literature. Moreover, Dr. S.'s opinion is consistent with Dr. F.'s treatment records listing hypertension as a risk factor for coronary artery disease. The Board accords limited probative weight to Dr. L.G.D.'s opinion because she did not explain why depression is not related coronary artery disease, and did not consider the medical study cited by Dr. S. Likewise, while Dr. L.G.D. listed other causes of coronary artery disease, she did not explicitly exclude hypertension as a cause. In sum, when weighing the conflicting evidence, the Board finds that the probative evidence of record supports the Veteran's claim. See Gilbert, 1 Vet. App. at 55. Accordingly, the Board finds that service connection is warranted for coronary artery disease secondary to service-connected depression and hypertension. See 38 C.F.R. § 3.310. Entitlement to service connection for kidney failure is granted. The Veteran asserts that service connection is warranted for kidney failure secondary to service-connected hypertension. An August 1968 entrance examination documented no abnormalities with the kidneys. Accordingly, the Board finds that the Veteran was in sound condition at entry to service. In August 2011, the Veteran's VA nephrologist, Dr. M.F., opined that the Veteran's chronic kidney disease was probably due to hypertensive nephrosclerosis. In September 2014, Dr. A.F. reviewed the Veteran's claims file and opined that the Veteran's kidney disease was probably due to a long history of hypertension. Dr. A.F. cited Dr. M.F.'s opinion and medical literature identifying hypertension as one of the two leading risk factors for the development of kidney failure. In March 2016, Dr. H.S. reviewed the Veteran's claims file and opined that it was as likely as not that kidney failure was permanently aggravated by hypertension. Dr. S. cited Dr. M.F.'s and Dr. A.F.'s opinions and American Heart Association research showing that hypertension is the leading cause for kidney failure. At a March 2021 VA examination, Dr. L.G.D. diagnosed the Veteran with chronic kidney disease. Dr. D. opined that it was less likely than not that the Veteran's kidney disease was proximately due to or aggravated by service-connected depression because hypertension and vascular disease are thought to be factors for kidney failure. It is undisputed that the Veteran has a current disability of kidney failure and is service connected, as a result of this decision, for hypertension. Therefore, the relevant issue is whether this current disability is secondary to service-connected hypertension. The Board finds that the Veteran's current disability of kidney failure is proximately due to service-connected hypertension. While Dr. S. opined that kidney failure was permanently aggravated by hypertension, his opinion also indicates that this disability was caused by hypertension. The Board accords probative weight to Dr. S.'s opinion because it was based on a thorough review of the Veteran's claims file and consistent with medical literature. Moreover, Dr. S.'s opinion is consistent with Dr. M.F.'s and Dr. A.F.'s opinions. The Board notes that Dr. L.G.D.'s opinion is not inconsistent with Dr. S.'s opinion. In sum, the Board finds that the probative evidence of record supports the Veteran's claim. See Gilbert, 1 Vet. App. at 55. Accordingly, the Board finds that service connection is warranted for kidney failure secondary to service-connected hypertension. See 38 C.F.R. § 3.310. REASONS FOR REMAND Entitlement to service connection for GERD is remanded. Remand is required to obtain an addendum to the October 2020 VA examiner's opinion. The examiner provided a negative nexus opinion because there were no available records to show that GERD was incurred in service. The examiner, however, improperly relied on the absence of evidence without providing a proper foundation. The examiner also did not consider the Veteran's assertion that this disability is related to contaminated water at Camp Lejeune. Entitlement to service connection for obstructive sleep apnea is remanded. Remand is required to obtain an addendum to the March 2021 VA examiner's opinion. The examiner opined that obstructive sleep apnea is due to the relaxation of the supporting structures of the neck during sleep and that depression is not a cause of obstructive sleep apnea. The examiner, however, did not consider the Veteran's assertions that his service-connected disabilities prevent him from wearing his CPAP mask and that antidepressant medications are known to be associated with sedation. The Board notes that VA treatment records appear to indicate that the Veteran's medications can result in sedation. In an April 2020 letter, the Veteran's attorney asserts that service connection is warranted based on Dr. H.S.'s opinion that the Veteran's obstructive sleep apnea was caused by and permanently aggravated by service-connected duodenal ulcer and depression as well as subsequent antidepressant usage. The attorney states that Dr. H.S. cited medical articles to support the opinion. Neither Dr. H.S.'s opinion nor the medical articles, however, are in the claims file. On remand, the attorney can resubmit this evidence for consideration. The matters are REMANDED for the following actions: 1. Obtain the Veteran's VA treatment records for the period from May 2021 to the present. 2. Ask the Veteran to complete a VA Form 21-4142 for any private treatment for GERD or obstructive sleep apnea. Make two requests for the authorized records from each provider, unless it is clear after the first request that a second request would be futile. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's GERD is at least as likely as not related to service, to include exposure to contaminated water at Camp Lejeune. The examiner must review the claims file and provide a rationale for all opinions. The examiner is advised that a negative opinion may not be based solely on the absence of treatment during or after service and that the examiner must provide a proper foundation explaining why the absence of evidence is relevant in determining whether the disability is related to service. The examiner is also advised that a negative opinion may not be based solely on the fact that GERD is not on the list of diseases that are presumptively associated with exposure to contaminated water at Camp Lejeune. 4. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's obstructive sleep apnea is proximately due to or aggravated by (i.e., worsened beyond its natural progression) service-connected duodenal ulcer and depression. The examiner must review the claims file and provide a rationale for all opinions. (Continued on the next page.) The examiner should consider the Veteran's assertions that he is unable to wear his CPAP mask consistently and that antidepressants result in sedation. The examiner should also consider VA treatment records that appear to indicate that the Veteran's medications can result in sedation. K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Ormson, 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.