Citation Nr: 21006650 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 15-00 715 DATE: February 4, 2021 REMANDED Entitlement to service connection for a right knee disorder, to include as secondary to weight gain due to service-connected posttraumatic stress disorder (PTSD) and obstructive sleep apnea, is remanded. Entitlement to service connection for a lumbar spine disorder, to include as secondary to weight gain due to service-connected PTSD and obstructive sleep apnea, is remanded. Entitlement to service connection for hypertension, to include as secondary to weight gain due to service-connected PTSD and obstructive sleep apnea, is remanded. Entitlement to service connection for a right hip disorder, to include as secondary to weight gain due to service-connected PTSD and obstructive sleep apnea, is remanded. Entitlement to service connection for a left hip disorder, to include as secondary to service-connected PTSD and obstructive sleep apnea, is remanded. Entitlement to service connection for diabetes mellitus, to include as secondary to weight gain due to service-connected PTSD and obstructive sleep apnea, is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1984 to December 1988 and from November 2001 to November 2002. These matters initially came before the Board of Veterans' Appeals (hereinafter Board) on appeal from an October 2013 rating decision, which reopened the claims of service connection for a low back disorder and hypertension, but denied the claims on the merits; that rating decision also denied claims of service connection for diabetes, service connection for a right knee disability, service connection for a right hip disability, and service connection for a left hip disability. The Veteran perfected a timely appeal to that decision. In June 2018, the Board remanded the case to the RO for evidentiary development. Following the requested development, a supplemental statement of the case (SSOC) was issued in April 2020. In a June 2020 decision, the Board determined that new and material evidence had been submitted and reopened the claims of service connection for a back disorder and service connection for hypertension, both claimed as secondary to wight gain due to service-connected PTSD and obstructive sleep apnea. The Board then remanded the case to the RO for further evidentiary development and a de novo review of the evidence. Following the requested development, an SSOC was issued in November 2020. The Board finds that there was substantial compliance with its remand; thus, it may proceed with a decision at this time. See Stegall v. West, 11 Vet. App. 268 (1998). In her substantive appeal (VA Form 9), dated in December 2014, the Veteran requested a videoconference hearing. However, in a statement dated in September 2015, the Veteran withdrew her request for a hearing. 1. Entitlement to service connection for a right knee disorder, to include as secondary to weight gain due to service-connected PTSD and obstructive sleep apnea is remanded. 2. Entitlement to service connection for a lumbar spine disorder, to include as secondary to weight gain due to service-connected PTSD and obstructive sleep apnea, is remanded. 3. Entitlement to service connection for hypertension, to include as secondary to weight gain due to service-connected PTSD and obstructive sleep apnea, is remanded. 4. Entitlement to service connection for a right hip disorder, to include as secondary to weight gain due to service-connected PTSD and obstructive sleep apnea, is remanded. 5. Entitlement to service connection for a left hip disorder, to include as secondary to service-connected PTSD and obstructive sleep apnea, is remanded. 6. Entitlement to service connection for diabetes mellitus, to include as secondary to weight gain due to service-connected PTSD and obstructive sleep apnea, is remanded. The Veteran essentially contends that she developed chronic low back pain, right knee pain and bilateral hip pain as a result of weight gain, which was caused by her PTSD with adjustment disorder with depressed mood. The Veteran contends that her current hypertension and diabetes mellitus is secondary to her service-connected PTSD with adjustment disorder with depressed mood. An August 2020 VA examiner opined that the Veteran’s hips, right knee and lumbar spine disorders were at least as likely as not aggravated beyond its natural progression by her service-connected PTSD with adjustment disorder with depressed mood. The examiner noted that it is well documented that PTSD in the veteran population often leads to social isolation, impaired functioning, mood changes, and weight gain, with a strong propensity for obesity related to an associated metabolic dysfunction. The examiner noted that the Veteran is obese. The examiner indicated that a brief conversation with the patient was conducted to provide information about the patient’s weight & body mass index (BMI) that indicates overweight/obesity, that there are health risks associated with overweight/obesity such as hypertension. The examiner explained that obesity is among the leading causes of immobility in adults. He further explained that an accumulation of excess body weight increases pressure on the joints, especially the back, hips, and knees; and over time, excess weight can cause cartilage in these joints to wear down, and this may lead to severe pain and difficulty walking. Therefore, the examiner concluded that Veteran's hips, right knee disorder, back disorder, hypertension and diabetes mellitus are at least as likely as not aggravated beyond its natural progression by her service-connected PTSD with adjustment disorder with depressed mood. However, the August 2020 VA examiner did not provide a baseline level of disability prior to aggravation. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 CFR part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). On remand, the examiner should attempt to provide a baseline level of disability prior to aggravation of the bilateral hip disorder, right knee disorder, lumbar spine disorder, hypertension and diabetes mellitus. The matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and her representative and afford her an opportunity to submit any copies in her possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, provide the claims file, to include a copy of this remand, to an appropriate medical professional for an addendum opinion to determine the baseline level of severity for the bilateral hip disorder, right knee disorder, lumbar spine disorder, hypertension and diabetes mellitus. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The examiner is asked to respond to the following question: The August 2020 VA opinion states that bilateral hip disorder, right knee disorder, lumbar spine disorder, hypertension and diabetes mellitus were at least as likely as not aggravated by the service-connected PTSD. The examiner must provide a baseline level of disability prior to aggravation. If unable to provide a baseline level of disability, please identify a date on which the PTSD began to have effects on the bilateral hip disorder, right knee disorder, lumbar spine disorder, hypertension and diabetes mellitus. In determining whether there is aggravation, the examiner should consider the Veteran's statements regarding onset and severity of her symptoms as competent and credible. Even if the examiner is unable to determine a baseline severity prior to the aggravation, the examiner is directed to the language of 38 C.F.R. § 3.310(b) which indicates that the baseline can be measured by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The examiner must set forth a complete rationale for any conclusion reached, citing to medical literature and/or evidence in the Veteran’s claims file as necessary. If an opinion cannot be reached without resorting to speculation, the examiner must fully explain why. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Suzie S. Gaston, 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.