Citation Nr: 21009016 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 13-17 704 DATE: February 18, 2021 REMANDED Entitlement to service connection for hypertension to include as secondary to service-connected disability is remanded. REASONS FOR REMAND The Veteran had active service from February 1968 to September 1969 in the United States Army with service in the Republic of Vietnam. Exposure to herbicide agents is presumed. 38 C.F.R. § 3.307(a)(6)(iii). This matter is on appeal from a September 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). His exposure to herbicide agents is presumed. 38 C.F.R. § 3.307(a)(6)(iii). In October 2017 and October 2019, the Board remanded the matter for additional development. During remand status, an August 2020 rating decision granted the claim of entitlement to service connection for bilateral upper extremity peripheral neuropathy. As this represents a full grant of the benefits sought on appeal with regard to those claims, there remains no controversy for the Board to consider. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (noting that a grant of service connection extinguishes appeals before the Board). It is noted that the Veteran’s representative, in his January 2021 Appellant’s Post-Remand Brief, argued that the Board in this appeal has jurisdiction of a claim of entitlement to a total rating based on individual unemployability (TDIU) prior to July 15, 2016, because the Veteran’s claim for service connection for hypertension was pending prior to that date. The Board disagrees. This appeal, at no time, has included a claim for increase; hence, TDIU is not part-and-parcel of any claim included in this particular appeal. Indeed, the record reflect that VA received a claim for TDIU in July 2016. See VA Form 21-526EZ (July 2016). Thereafter, a November 2016 rating decision granted a 70 percent rating for posttraumatic stress disorder (PTSD) and TDIU, each from July 15, 2016 (date of claim for increased compensation). See Rating Decision (November 2016). A November 2016 letter notified the Veteran of that decision and how to appeal. VA received no appeal. The November 2016 rating decision became final. Given the above, the matter of an earlier effective date for the award of TDIU is not before the Board at this time. See generally, Rudd v. Nicholson, 20 Vet. App. 296 (2006) (finding that only a request for revision based on clear and unmistakable evidence could result in the assignment of an effective date earlier than the date of a final decision). Further, it is noted that the Veteran’s representative has challenged the qualifications of the Physician Assistant who provided the recent January 2020 VA medical opinion. See Francway v. Wilkie, 930 F.3d 1377, 1380 (Fed. Cir. 2019). However, as the Board has found the opinion inadequate, this challenge is moot. Lastly, it is noted that the Veteran’s representative argues that the criteria for secondary service connection are met based on studies, not considered by the most recent VA medical opinion, which show a link between PTSD (and chronic sleep impairment) and hypertension. The representative cited to general medical treatise material (e.g. Cecil Textbook of Medicine; an article “Post-traumatic Stress Disorder and Cardiovascular Disease, 2011, published in The Open Cardiovascular Medicine Journal) along with information from the Centers for Disease Control (CDC) http://www.cdc.gov/sleep/about_sleep/chronic_disease.htm). The Board accepts that a medical article or treatise can provide important support when combined with an opinion of a medical professional if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least “plausible causality.” See Mattern v. West, 12 Vet. App. 222, 228 (1999); see also Sacks v. West, 11 Vet. App. 314 (1998). However, here, the representative did not provide a copy of the relevant textual materials, only summarizing or extracting that part supporting the theory, and he did not provide any accompanying medical opinion. Further, the medical literature referenced is not constructively before the Board simply by virtue of the representative’s reference broad thereto or including a hyperlink. Indeed, “medical literature” is not veteran-specific unlike VA treatment records or relevant non-VA records reasonably identified. It is noted that, although the Board may be generally aware of a study, this does not place it constructively before the Board and does not trigger alone VA’s duty to assist by obtaining a supplemental opinion. See generally, Euzebio v. Wilkie, 31 Vet. App. 394 (2019), citing Monzingo v Shinseki, 26 Vet. App. 97, 102 (2012). Entitlement to service connection for hypertension to include as secondary to service-connected disability is remanded. The Veteran seeks service connection for hypertension. He has, along with his representative, argued in favor of both direct and secondary service connection. As to direct service connection, it is argued that the Veteran’s hypertension is due to or the result of conceded in-service herbicide agent exposure. As to secondary service connection, it is argued that his hypertension is due to or the result of service-connected disability, specifically, diabetes mellitus, coronary artery disease, and/or PTSD; or alternatively, aggravated by service-connected disability. See Appellate Brief (January 2021). Although a January 2020 VA medical opinion (VAMO) was obtained addressing whether the Veteran’s hypertension is secondary to service-connected PTSD, the Board finds that the VAMO is inadequate for adjudicative purposes. The opinion dismissed the research showing an increased risk of hypertension among Veterans diagnosed with PTSD based on methodological flaws, which are not clearly elucidated, and because an association was not necessary evidence of a causal relationship. The VAMO concluded that hypertension was not caused by or the result of PTSD because the favorable research was methodologically flawed and because “the Veteran has been diagnosed and treated for PTSD since 1996 and also has co-morbid conditions which are risk factors for developing hypertension (Sleep apnea, PVD, Aortic atherosclerosis, type 2 Diabetes Mellitus) - there is no established medical nexus for the etiology of the HTN proximately due to the SC PTSD.” Here, first, the medical opinion is inadequate because it did not clearly explain why the referenced studies showing an association between hypertension and PTSD were insufficient to support a finding that there was a causal relationship, at least as likely as not. Indeed, the opinion does not explain the difference between an “association” versus “causation,” in the context of medical research and studies whereby an association can arise between variables in the presence and absence of a causal relationship. Second, the medical opinion acknowledged that the Veteran had other risk factors for developing hypertension that included diabetes. However, it did not address whether the Veteran’s diabetes mellitus, a service-connected disability, at least as likely as not, resulted in or caused his hypertension. It is also noted that a medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record. See Stefl v. Nicholson, 21Vet. App.102, 124-25. A “medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two.” Nieves-Rodriguez v. Peake, 22Vet. App.295, 301 (2008). Further, the Board finds that November 2017 VAMO is inadequate. The VAMO reflects the conclusion that hypertension was less likely than not caused by or aggravated by service-connected diabetes (DM) or coronary artery disease (CAD). The rationale was “High blood pressure is a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease. There is no medical evidence to support the veterans claim that his current condition is related to service or aggravated beyond its natural progression due to DM or CAD.” The opinion does not reflect any meaningful consideration of this Veteran’s facts and it lacks separate findings and rationales must as to the causation and aggravation prongs which are separate concepts. See Atencio v. O'Rourke, 30 Vet. App. 74, 8991 (2018). Lastly, a medical opinion supported by a rational on the question of direct service connection has not been obtained. In this regard, it is noted that, although hypertension is not a disease enumerated as presumptively associated with herbicide agent exposure, nonetheless, service connection may be established with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); see also McCartt v. West, 12 Vet. App. 164, 167-68 (1999) (providing that the provisions set forth in Combee are equally applicable in cases involving claimed Agent Orange exposure). The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from August 2020 to present. 2. Obtain an addendum opinion from an appropriate clinician regarding etiology of the Veteran’s hypertension. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. The opinion should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). If the Veteran has various risk factors for the development of hypertension, identify which is/are more likely the cause of the Veteran’s hypertension and fully explain. The clinician must opine on: Direct Service Connection (a) Whether hypertension is at least as likely as not is related to an in-service injury, event, or disease, to include in-service exposure to herbicide agents. Explain. Secondary Service Connection (b) Whether hypertension is at least as likely as not (1) proximately due to service-connected diabetes mellitus; or (2) aggravated beyond its natural progression by service-connected diabetes mellitus. Explain. (c) Whether hypertension is at least as likely as not (1) proximately due to service-connected coronary artery disease; or (2) aggravated beyond its natural progression by service-connected coronary artery disease. Explain. (d) Whether hypertension is at least as likely as not (1) proximately due to service-connected PTSD; or (2) aggravated beyond its natural progression by service-connected PTSD. Explain. NOTE (1): An adequate opinion requires separate findings and rationales as to the causation and aggravation prongs of secondary service connection. NOTE (2): An adequate opinion may not rely on the absence of medical literature supporting causation without discussing the Veteran-specific facts of the case. 3. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. A. Macek, 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.