Citation Nr: 21006258 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 14-23 336 DATE: February 3, 2021 REMANDED Entitlement to service connection for vertigo, including as secondary to service-connected posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for an eye disability, including blurred vision, amblyopia with astigmatism, allergic conjunctivitis, hypertensive retinopathy with right retinal vein occlusion, and primary open angle glaucoma, as secondary to service-connected PTSD is remanded. Entitlement to service connection for obstructive sleep apnea, including as secondary to service-connected PTSD is remanded. Entitlement to service connection for hypertension, including as secondary to service-connected PTSD is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD), including as secondary to service-connected PTSD is remanded. Entitlement to service connection for anemia, including as secondary to service-connected PTSD is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU), prior to January 8, 2018 is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Navy from December 1964 to November 1966. This appeal arises from a February 2012 rating decision, denying service-connection for anemia and a TDIU. This appeal also arises from an August 2013 rating decision, denying service-connection for hypertension and GERD. This appeal also arises from a July 2017 rating decision, denying service-connection for obstructive sleep apnea. This appeal also arises from a November 2017 rating decision, denying service-connection for vertigo and eye disorders (claimed as blurred vision), identified as amblyopia with astigmatism, allergic conjunctivitis, hypertensive retinopathy, and primary open angle glaucoma. Notably, the Board has characterized the issue of entitlement to service connection for an eye disability to include all of the various identified and claimed eye conditions, as listed above. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). In February 2016, the Board remanded the issues of anemia, hypertension, GERD and a TDIU to the AOJ for additional development and consideration. In June 2018, the Board denied the Veteran’s service-connection claims for hypertension and GERD, and remanded the anemia and TDIU issues. The Veteran appealed the Board's June 2018 decision to the United States Court of Appeals for Veterans Claims (CAVC/Court). In a November 2019 non-precedential Memorandum Decision, the Court vacated the Board’s denials of service-connection for hypertension and GERD and remanded this case to the Board for further development and readjudication. In May 2020, the Board remanded the issues of anemia, hypertension, GERD and a TDIU to the AOJ for additional development and consideration. During the pendency of the appeal, a June 2018 rating decision increased the Veteran’s rating assignment for posttraumatic stress disorder (PTSD) from 50 percent to 100 percent, effective from January 8, 2018. The Board’s May 2020 remand also denied an increased rating in excess of 50 percent for PTSD prior to January 8, 2018. A June 2018 rating decision then found the issue of a TDIU moot due to his receipt of a 100 percent rating, but later that month, the Board’s June 2018 Board decision remanded the TDIU issue. Presently, the Board observes that although the issue of a TDIU is moot from January 8, 2018, the issue of entitlement to a TDIU prior to January 8, 2018 remains pending. The file is again before the Board for further appellate review. 1. Entitlement to service connection for vertigo, including as secondary to service-connected posttraumatic stress disorder (PTSD) is remanded. 2. Entitlement to service connection for an eye disability, including blurred vision, amblyopia with astigmatism, allergic conjunctivitis, hypertensive retinopathy with right retinal vein occlusion, and primary open angle glaucoma, as secondary to service-connected PTSD is remanded. The Veteran asserts his vertigo and eye conditions are due to side effects of PTSD medication called Sertraline, and cites the listed side effects for that medication as including dizziness, blindness, blurred vision, decreased vision and changes in vision. See January 2020 Veteran’s attorney’s brief. The Board finds a VA examination and medical opinion would be helpful to resolve the nature and etiology of the Veteran’s claimed vertigo and eye disorder, including whether any disorder was caused or aggravated by service-connected PTSD, including PTSD medications. 3. Entitlement to service connection for obstructive sleep apnea, including as secondary to service-connected PTSD is remanded. The Veteran’s attorney’s January 2020 brief has cited medical literature in support of the notion that the Veteran’s obstructive sleep apnea was caused or aggravated by service-connected PTSD. A December 2017 VA examiner provided a negative opinion against the possibility that the Veteran’s diagnosed obstructive sleep apnea was caused or aggravated by service-connected PTSD, with an inaccurate premise that the Veteran had not taken any PTSD medication since 2009. The Veteran had stopped Sertraline medication in 2008. However, VA treatment records note he restarted Sertraline medication in a June 2017 primary care visit to treat his PTSD, but appeared to switch to yet another PTSD medication, Paroxetin, in December 2017. The Board finds another VA medical opinion is needed on whether the Veteran’s sleep apnea was caused or aggravated by service-connected PTSD, including PTSD medications. When VA undertakes to examine a Veteran, VA is obligated to ensure that that examination is adequate. See Barr v. Nicholson, 21. Vet. App. 303 (2007). Inadequate medical examinations include examinations that contain only data and conclusions, do not provide an etiological opinion, are not based upon a review of medical records, or provide unsupported conclusions. Nieves- Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). 4. Entitlement to service connection for hypertension, including as secondary to service-connected PTSD is remanded. 5. Entitlement to service connection for GERD, including as secondary to service-connected PTSD is remanded. The May 2020 Board remand directed the AOJ to obtain medical opinions on the possibility that hypertension and GERD, respectively, were related to the same traumatic events that established service-connected PTSD. On remand, an October 2020 VA examiner provided negative opinions against the possibility that the Veteran’s hypertension and GERD, respectively, were due to traumatic events which are the basis of his now service-connected PTSD. However, in response, the Veteran’s attorney, in a January 2021 brief, argued that the October 2020 VA examiner’s opinion is inadequate for not also addressing whether these disabilities may have been caused or aggravated by PTSD, in consideration of such traumatic events. The brief also cited and submitted medical literature in support of co-morbidities for hypertension and PTSD, and the relation between gastrointestinal problems and PTSD. The Board finds an addendum opinion should be provided on the Veteran’s hypertension and GERD were caused or aggravated by service-connected PTSD, including PTSD medications. 6. Entitlement to service connection for anemia, including as secondary to service-connected PTSD is remanded. An October 2020 VA examiner provided a negative nexus opinion against the notion that anemia is related to the Veteran’s service or any service-connected disability. As noted by the attorney’s January 2021 brief, the examiner did not consider the effect of the Veteran’s PTSD medications on anemia and related symptoms. The Board finds an addendum opinion should be provided on the Veteran’s anemia was caused or aggravated by service-connected PTSD, including PTSD medications. 7. Entitlement to a TDIU prior to January 8, 2018 is remanded. Notably, the Veteran established a 100 percent rating for service-connected PTSD from January 8, 2018; however, the period prior to January 8, 2018 remains pending. The Veteran first established schedular eligibility for a TDIU on May 1, 2011. 38 C.F.R. § 4.16 (a). The Veteran’s statements have asserted TDIU as due to his service-connected PTSD medications as well as coronary artery disease (CAD), and prostate cancer. He has reported occupational history as a Merchant Marine, fire guard and security guard, with a high school education. The Veteran reported that he last worked as a security guard from May 2015 through December 2017, when he earned approximately $15,000 annually and worked 31 hours pe week. See February 2018 TDIU applications; and April 2016 VA PTSD examination. Thus, it appears the Veteran has asserted entitlement to a TDIU based on marginal employment for this period of the appeal. The Board notes that an April 2016 VA examiner found his PTSD did not hinder him from sustaining his then-current employment as a fire-guard, in which he reportedly worked for 32 hours per week. In contrast, a February 2018 VA heart examination, proximate to the period on appeal, indicated that his service-connected heart condition might prevent him from doing physical labor (heavy lifting, running, climbing, strenuous activities), but does not preclude sedentary employment. The Board notes that the Veteran has not reported any history of sedentary-type employment. The Board finds a retrospective medical opinion from a VA clinician would be helpful to assess any occupational impairments the Veteran suffered prior January 8, 2018, particularly any collective impact of all service-connected disabilities.  The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the claimed vertigo and eye disability. The examiner should elicit and consider the Veteran’s lay statements on the history of his vertigo and eye conditions. (a) The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater) that any diagnosed vertigo or eye disorder is related to service. (b) The examiner should express an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any diagnosed vertigo or eye disability was caused and/or aggravated by service-connected PTSD. The examiner must consider and discuss any impact of medications for the Veteran’s service-connected PTSD. A complete rationale should be provided for all opinions rendered. 2. Obtain a VA medical opinion by an appropriate clinician, different than the December 2017 VA examiner, to determine the etiology of the Veteran’s sleep apnea, hypertension, GERD, and anemia. Specifically, the examiner should opine as to the following: (a) Whether it is at least as likely as not that the Veteran’s sleep apnea, hypertension, GERD, and/or anemia is related to service. (b) Whether it is at least as likely as not that the Veteran’s sleep apnea, hypertension, GERD, and/or anemia was caused or aggravated by his service-connected PTSD. The examiner must consider and discuss any impact of medications for the Veteran’s service-connected PTSD. A complete rationale should be provided for all opinions rendered. 3. Obtain an addendum medical opinion from a qualified VA clinician on the Veteran’s TDIU claim.  The clinician should indicate that the record was reviewed.  On review of the record, the clinician(s) should identify all limitations or functional impairment, concerning the Veteran’s prior employment as a security guard, fire guard and Merchant Marine, for the period prior to January 8, 2018, as: (a) due solely to his service-connected PTSD, CAD, prostate cancer, skin disability, painful scar, or erectile dysfunction; or (b) due to all of his service-connected disabilities combined.  The examiner must consider and discuss any impact of medications for the Veteran’s service-connected PTSD.   Rationale must be provided for the opinions expressed.  C. CRAWFORD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Biswajit Chatterjee, 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.