Citation Nr: 21008737 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 20-16 532 DATE: February 17, 2021 REMANDED Entitlement to service connection for hypertension as secondary to service-connected disability is remanded. Entitlement to service connection for erectile dysfunction as secondary to service-connected disability is remanded. REASONS FOR REMAND The Veteran served active duty in the United States Army from April 1966 to April 1968, with service in Vietnam from 1966 to 1967. This matter comes to the Board of Veterans’ Appeals (Board) on appeal of a December 2017 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO) in Atlanta, GA. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show: (1) that a current disability exists, and (2) that the current disability was either (a) caused by, or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a); Allen v. Brown, 7 Vet. App. 439 (1995). 1. Entitlement to service connection for hypertension as secondary to service-connected disability is remanded. The Veteran contends he is entitled to service connection for hypertension under a secondary service connection theory of entitlement. The Veteran is currently service-connected for other specified trauma and stressor-related disorder (claimed as PTSD). The Veteran asserts his hypertension is related to his service-connected PTSD as it has been shown to directly trigger high blood pressure, and is also a side-effect of his PTSD medications. The Veteran was provided a VA examination in December 2017. The examiner noted the Veteran’s diagnosis date of April 1998, but opined his hypertension was less likely than not proximately due to or the result of his PTSD. The examiner concluded, “while an anxiety state (PTSD) can cause a temporary elevation in blood pressure mental health conditions (PTSD) is not a risk factor for or a cause for hypertension. The etiology of primary hypertension and identifiable or secondary hypertension (due to a known cause) differ.” The examiner indicated known risk factors for developing primary hypertension are race, family history, sodium intake, alcohol intake, dyslipidemia, and physical inactivity, with a major risk factor being obesity and weight gain. The examiner provided a negative nexus opinion on the Veteran’s hypertension as a direct result of PTSD, however, the examiner did not opine on the issue of aggravation as required for a secondary theory of entitlement. Additionally, the examiner did not discuss the Veteran’s contention that his PTSD medications (SSRIs) caused him to develop his hypertension. The Board finds the examination inadequate for compensation purposes and remand is necessary to address deficiencies in the opinion. Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). The Board notes, in February 2021, the Veteran’s representative submitted a brief presenting new contentions regarding a potential relationship between his hypertension, obesity, and PTSD, medications, or other service-connected disabilities. The Veteran is additionally service-connected for several foot disabilities incurred during service. The representative asserts the Veteran’s foot conditions have caused him to become limited in physical activity which has resulted in weight gain and obesity; he also notes VA has linked PTSD to physical inactivity and weight gain. Although the VA does not consider obesity a standalone disease, obesity can be an “intermediate step” between a service-connected disability and a current disability if proximate causation is shown. VAOPGCPREC 1-2017; See Walsh v. Wilkie, 32 Vet. App. 300, 305-07 (2020). Here, proximate causation would be established if: (1) PTSD and/or pes planus and hammertoes caused the Veteran to become obese; (2) obesity was a substantial factor in causing hypertension; and (3) hypertension would not have occurred but for the obesity that was caused by the service-connected disabilities. The representative has included several sources of medical literature to support the contention the Veteran’s obesity was proximately caused by his physical and mental disabilities. The record also contains mental health assessments noting the Veteran’s history of “stress eating” when considering which medications were appropriate for his PTSD, and the Veteran’s difficulty in managing his weight and dieting properly. See CAPRI, 1/29/2020, pg 145. As the 2017 examiner opined obesity and weight gain is a major factor related to hypertension, an examiner should opine on the contentions and address obesity as an intermediate step of secondary service connection. Further, the Veteran contends his use of NSAID medication for his foot conditions has caused his hypertension and submits medical literature in support. On remand, an opinion should also be obtained which reviews this literature and discusses any relationship to the Veteran’s medications for his foot disability and PTSD. 2. Entitlement to service connection for erectile dysfunction as secondary to service-connected disability is remanded. The Veteran contends he is entitled to service connection for erectile dysfunction (ED) under a secondary theory of entitlement. He asserts his condition has resulted from medications he is prescribed for his service-connected PTSD, specifically SSRIs. The December 2017 examiner noted the Veteran’s ED diagnosis as July 2015 but opined it was less likely than not proximately due to or the results of his PTSD. He notes, “Review of current medical literature and research shows no physiologic or biomechanical causal relationship between a mental health condition (PTSD) and erectile dysfunction.” The examiner indicates, in most cases, ED is caused by something physical and provides several common causes. Of the risk factors listed, obesity, prescription medications, and high blood pressure are relevant to the claim. However, the examiner did not provide an opinion on whether the Veteran’s ED was aggravated by his service-connected PTSD or address the Veteran’s contention his medication has caused the condition. The Veteran’s February 2021 brief included additional arguments regarding the relationship between the Veteran’s ED and service-connected disabilities. The representative asserts the examiner did not thoroughly review treatment records revealing the onset and cause of the condition. In a March 2018 mental health treatment note, the Veteran indicated to the psychologist his ED began in April 2016, shortly after starting Duloxetine (an SSRI) for PTSD. See CAPRI, 1/29/2020, pg. 168/215. The representative asserts ED is a known side effect of SSRIs and the examiner failed to consider this. As treatment records from 2020 indicate the Veteran has since changed medications related to PTSD, review of the Veteran’s treatment history and a medical opinion is necessary to fully address the Veteran’s assertions. See CAPRI, 1/29/2020, pg 1. On remand, an addendum opinion should also be obtained which reviews and discusses the medical literature and contentions submitted by the Veteran. Additionally, the Veteran has indicated his ED may be due to his hypertension. The Board has remanded the claim of service connection for hypertension herein. To the extent that the outcome of that claim may have a direct bearing on the Veteran’s claim of service connection of ED, those issues are inextricably intertwined. Accordingly, these matters are REMANDED for the following action: 1. Provide the Veteran’s claims file to an appropriate clinician in order to obtain addendum opinions regarding the nature and etiology of the Veteran’s claimed conditions. The examiner should opine on the Veteran’s hypertension as to: (a.) whether it is at least as likely as not (at least a 50 percent likelihood) that the Veteran’s PTSD or foot disabilities, including medications taken for each, proximately caused the Veteran’s hypertension. (b.) whether it is at least as likely as not (at least a 50 percent likelihood) the Veteran’s PTSD or foot disabilities, including medications taken for each, aggravated beyond natural progression the Veteran’s hypertension. Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. The examiner should opine on the Veteran’s erectile dysfunction as to: (a.) whether it is at least as likely as not (at least a 50 percent likelihood) that the Veteran’s PTSD or foot conditions, including medications, proximately caused the Veteran’s erectile dysfunction. (b.) whether it is at least as likely as not (at least a 50 percent likelihood) the Veteran’s PTSD or foot conditions, including medications, aggravated beyond natural progression the Veteran’s erectile dysfunction. Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions The examiner should opine as to both conditions: (a.) Is it at least as likely as not that the Veteran’s service-connected PTSD and/or foot disabilities, either alone or in combination, caused him to become obese? (b.) If so, then is it at least as likely as not that such obesity was a substantial factor in causing any of the claimed disabilities of hypertension and ED? (c.) Is it at least as likely as not that the Veteran’s hypertension and erectile dysfunction would not have occurred but for the obesity? The examiner is asked to provide the underlying reasons for all opinions expressed, and is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T.N. Chapman, 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.