Citation Nr: 21072692 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 15-08 974 DATE: December 6, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected PTSD and duodenal ulcer is remanded. Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to PTSD and duodenal ulcer is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1969 to May 1971, including service in the Republic of Vietnam. He also had additional service in the United States Army National Guard. The claims were most recently before the Board in May 2021 when they were remanded for additional development. There has not been substantial compliance with the Board's remand directives and the claims must be remanded again. Stegall v. West, 11 Vet. App. 268 (1998). In a December 2020 decision, the Board denied entitlement to service connection for a right knee disability. In an October 2021 order, the United States Court of Appeals for Veterans Claims (Court) granted a Joint Motion for Partial Remand vacating the portion of the December 2020 Board decision denying this issue. As the necessary time for response from the Veteran regarding this issue has not elapsed, this issue is not ripe for consideration and, therefore, will be considered in a subsequent Board decision. 1. Entitlement to service connection for a low back disability is remanded. A VA medical opinion was obtained in January 2021. The examiner found that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that during service, the Veteran's lumbar spine condition, was acute only. There was no evidence of chronicity of care and symptoms are subjective only. The examiner identified that in 2001 and 2002 the Veteran was fit without symptoms, then in 2005 to 2007 lifting boxes at work emergency room visits noted then to present. The examiner stated that there was no nexus to acute service-related injury as is common in many acute injury. A VA medical opinion report was prepared in July 2021. The examiner found that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner indicated that the service treatment records were negative for any diagnosis or complaints of the lumbar spine during active-duty service and that examination of the Veteran's spine at separation was normal. The examiner reported that the Veteran suffered a lumbar strain in 1994 due to taking on and off chemical exposure suit and was treated with noralgesic and rest for 5 days. There was no evidence of chronic lumbar condition manifesting from this acute strain. The Veteran was seen again in 1999 for low back pain (LBP) after slipping off a ladder. The examiner noted that the Veteran's currently diagnosed lumbar degenerative disc disease was identified on magnetic resonance imaging (MRI) in 2011, many years after service and unrelated to the strains occurring in 1994 and 1999. Another VA medical opinion was obtained in July 2021. The examiner noted that although the January 2021 medical opinion noted temporary aggravation of a pre-existing condition, the current examiner was unable to locate evidence of a pre-existing lumbar spine condition. The Veteran's entrance examination from 1968 noted a normal spine and no comments about a pre-existing back injury, treatment or condition. The Board finds that these medical opinions are not adequate to adjudicate the issue on appeal. The January and July 2021 opinions afforded regarding whether the disability is directly related to service are not adequate because they do not provide adequate rationale as to why the Veteran's identified in-service acute injury did not contribute to the Veteran's current disability. 2. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD is remanded. A VA medical opinion was obtained in July 2021. The examiner rendered the opinion that hypertension was less likely than not incurred in or caused by the Veteran's active service. However, the rational provided was that there was no diagnosis or complaint of hypertension during active service or for years thereafter. The Board finds that this opinion is not adequate because it relies upon a lack of diagnosis or complaint in service. See Dalton v. Nicholson, 21 Vet. App. 23 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (that reports of symptomatology are not supported by contemporaneous clinical evidence does not render them inherently not credible). The examiner also opined that the Veteran's condition was not at least as likely as not aggravated beyond its natural progression by the service-connected disability. The examiner noted that while research has shown that stress due to emotional and/or psychological issues (PTSD) can cause temporary elevations in blood pressure there is no scientific basis for the etiology of hypertension due to PTSD/stress. The examiner described the causation of the disability and reported that prolonged smooth muscle constriction is thought to induce structural changes with thickening of the arteriolar vessel walls possibly mediated by angiotensin, leading to an irreversible rise in peripheral resistance. The examiner found that there was no evidence of increased flare ups, evaluations or treatment of the HTN due to the PTSD. However, although the examiner indicates that psychological issues can cause temporary elevations in blood pressure, the examiner does not adequately resolve why temporary elevations in blood pressure do not aggravate the identified irreversible rise in peripheral resistance. As the medical opinions are not adequate to resolve the issue on appeal, the claim must be remanded for an adequate VA medical opinion. 3. Entitlement to service connection for GERD, to include as secondary to service-connected PTSD and duodenal ulcer is remanded. A medical opinion was obtained in July 2021. The examiner found that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reported that the service treatment records were negative for any diagnosis or complaints of GERD during active-duty service. The examiner found that the records were silent for GERD or any gastrointestinal complaints until 2007 with noted likely reflux and acid suppression medication. The examiner stated that the claims folder support chronic medication for dyspepsia; however, there was a lack of evidence substantiating that the GERD manifested during active duty or as a result of service. The medical opinion provided regarding whether the Veteran's disability is directly related to service is not adequate because it relies upon a lack of notation of GERD during service. See id. Therefore, the claim must be remanded to obtain an adequate medical opinion. 4. Entitlement to service connection for OSA, to include as secondary to PTSD and duodenal ulcer is remanded. The Veteran was afforded a VA examination in July 2021. The examiner rendered the opinion that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reported that the service treatment records are negative for any diagnosis or complaints of OSA during active-duty service and that the Veteran's first documented complaint was in 2008. The medical opinion provided regarding whether the Veteran's disability is directly related to service is not adequate because it relies upon a lack of notation during service. See id. Therefore, the claim must be remanded to obtain an adequate medical opinion. The matters are REMANDED for the following action: 1. Take all appropriate action to associate with the claims file all outside treatment records scanned into CPRS and VISTA. 2. Ask the Veteran to complete a VA Form 21-4142 for private treatment, including from University of Nebraska, Nebraska Spin Center and Innovative Pain and Spine Specialists. Make two requests for the authorized records from all identified providers including from Nebraska Spin Center and Innovative Pain and Spine Specialists, unless it is clear after the first request that a second request would be futile. 3. Thereafter, obtain opinions from appropriate clinicians regarding the likely etiology of the Veteran's low back, hypertension, GERD, and OSA disabilities. Copies of all pertinent records must be made available to the examiner for review. An examination of the Veteran is not required unless deemed necessary by the examiner. The examiner(s) must answer the following: (a) Is it at least as likely as not that the Veteran's low back, hypertension, GERD, and OSA disabilities are related to an in-service injury, event, or disease? In rendering the opinion, the examiner should comment on the in-service acute injury of the back. (b) If the Veteran's hypertension disability is not directly related to service, is it at least as likely as not (1) proximately due to service-connected disabilities, including any medication used to treat any service-connected disability, or (2) aggravated by any service-connected disability, including any medication used to treat any service-connected disability. Aggravation here is defined as any increase in disability. The examiner should consider and comment on as necessary the impact of potential temporary elevations in blood pressure due to any service-connected disabilities. A complete rationale should be provided for all opinions expressed. Patrick M. Johnson Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Robert J. Burriesci, 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.