Citation Nr: 21010821 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 19-12 764 DATE: February 25, 2021 REMANDED The issue of service connection for hypertension is remanded. The issue of service connection for gout is remanded. The issue of service connection for a gastrointestinal disorder is remanded. The issue of a total disability rating based on individual unemployability (TDIU). REASONS FOR REMAND The Veteran served on active duty from May 1959 to April 1961, and from May 1961 to June 1988. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a June 2015 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). This matter was remanded in January 2020 for further development. The Board also remanded the issue of service connection for kidney disease. The RO issued an October 2020 rating decision in which it granted service connection for interstitial nephritis (chronic kidney disease, stage 3). The grant of service connection constitutes a complete grant of the claim. Consequently, the Board does not have jurisdiction over the matter. The issue of service connection for hypertension is remanded. In a January 2021 correspondence, the Veteran’s representative argued that both the February 2020 VA examiner and the RO have failed to address the contention that the Veteran’s hypertension is secondary to his service connected posttraumatic stress disorder (PTSD). In a May 2019 correspondence, the representative argued that hypertension was secondary to PTSD. He cited a 2009 article entitled Hypertension in Relation to Posttraumatic Stress Disorder and Depression in the US National Comorbidity Study. Additionally, the representative argued that obesity may be used as an intermediate step between a Veteran’s disability and service connection. See Walsh v. Wilkie, 32 Vet. App. 300 (2020); see also VAOGCPREC 1-2017. The February 2020 VA examiner noted that risk factors for primary hypertension include obesity, weight gain, and physical inactivity. The examiner also noted that risk factors for secondary hypertension include acute/chronic kidney disease. The Board finds that a medical opinion is needed to address the contention that hypertension was caused or aggravated by his service connected PTSD, and to address the contention that the Veteran’s obesity was caused by service-connected disabilities such as PTSD, a back disability, and a right foot disability. The issue of service connection for gout is remanded. The Veteran’s representative has noted that in a October 2020 medical opinon, the examiner opined that the Veteran’s acute gouty attacks and elevated uric acid are related to alcohol, diet and lifestyle, along with the aging process. Though the examiner did not specify what was meant by the Veteran’s “lifestyle,” it appears that the examiner may be referring to the Veteran’s sedentary and physically inactive lifestyle. If so, the representative argues that such a lifestyle is due to his service-connected disabilities such as PTSD, a back disability, and a right foot disability. An addendum should be obtained to determine what aspect of the Veteran’s “lifestyle” has caused the Veteran’s gout, and whether that “life-style” is due to service-connected disabilities such as PTSD, a back disability, and a right foot disability. The issue of service connection for a gastrointestinal disorder is remanded. A February 2020 VA examiner opined that the Veteran’s gastrointestinal disorder was less likely than not caused or aggravated by the Veteran’s service connected disabilities; however, as the Veteran’s representative noted in a January 2021 correspondence, the examiner did not discuss any of these disabilities. Specifically, the examiner failed to address whether a gastrointestinal disorder was caused or aggravated by the Veteran’s service-connected PTSD. In a May 2019 correspondence, the Veteran’s representative stated that recent studies have shown a link between these conditions and PTSD. The representative did not cite any specific study. The Board finds that an opinion is needed to address the contention that PTSD caused or aggravated the Veteran’s gastrointestinal disorder. The issue of a TDIU is remanded. The Veteran’s claim for a TDIU is dependent on whether the Veteran’s service-connected disabilities render him unable to secure or follow a substantially gainful occupation. As such, the claim is inextricably intertwined with the issue of whether service connection is warranted for a gastrointestinal disability, hypertension, and gout. The matters are REMANDED for the following action: 1. The RO must obtain a medical opinion (via a medical examination only if necessary). The examiner must provide an opinion as to the following: Is the Veteran’s hypertension at least as likely as not proximately caused his service-connected PTSD? Is the Veteran’s hypertension at least as likely as not aggravated, i.e., worsened beyond its natural progression, by his service-connected PTSD? The examiner should reconcile his/her findings with the evidence cited by the Veteran (a 2009 article by Dr. Jeffrey L. Kibler entitled Hypertension in Relation to Posttraumatic Stress Disorder and Depression in the US National Comorbidity Study). Is the Veteran’s hypertension at least as likely as not proximately caused by his service-connected interstitial nephritis (chronic kidney disease, stage 3)? Is the Veteran’s hypertension at least as likely as not aggravated, i.e., worsened beyond its natural progression, by his service-connected interstitial nephritis (chronic kidney disease, stage 3)? If the Veteran’s hypertension is in part due to obesity and physical inactivity, is the obesity and/or physical inactivity due to service-connected disabilities such as PTSD, a back disability, and a right foot disability? 2. Obtain an addendum opinion regarding what aspect(s) of the Veteran’s “lifestyle” (weight, inactivity, sedentary, etc.) have contributed to his gout. The examiner should opine whether these aspects of the Veteran’s “lifestyle” are at least as likely as not related to service-connected disabilities such as PTSD, a back disability, and a right foot disability. 3. Obtain an addendum opinion regarding whether the Veteran’s gastrointestinal disability is at least as likely as not (1) proximately caused by his service-connected PTSD, and (2) aggravated beyond its natural progression by his service-connected PTSD. The examiner should reconcile his/her findings with medical literature and studies that have linked PTSD with gastrointestinal disorders. JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Prem, 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.