Citation Nr: 21011622 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 17-01 853 DATE: March 2, 2021 ORDER New and material evidence having been received, the appeal to reopen the claim of entitlement to service connection for hair loss on face and head (alopecia areata) is granted. New and material evidence having been received, the appeal to reopen the claim of entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD) and major depressive disorder, is granted. New and material evidence having been received, the appeal to reopen the claim of entitlement to service connection for hypertension is granted. Service connection for hair loss on face and head (alopecia areata) is granted. REMANDED The claim of entitlement to service connection for a right knee disability is remanded. The claim of entitlement to service connection for a left knee disability is remanded. The claim of entitlement to service connection for an acquired psychiatric disability, to include PTSD and major depressive disorder, is remanded. The claim of entitlement to service connection for hypertension is remanded. FINDINGS OF FACT 1. A March 2004 rating decision denied the claim of entitlement to service connection for hair loss, a psychiatric disability, and hypertension; the Veteran did not file a timely notice of disagreement, and no evidence was received within one year of the rating decision, nor were new, relevant service records received any time thereafter. 2. The evidence associated with the claims file subsequent to the March 2004 rating decision denying service connection for hair loss, a psychiatric disability, and hypertension is not cumulative, relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim. 3. The evidence is at least in equipoise as to whether the Veteran’s hair loss began during active service and have been continuous to the present. CONCLUSIONS OF LAW 1. The March 2004 rating decision, which denied service connection for hair loss, a psychiatric disability, and hypertension, became final. 38 U.S.C. § 7105(a); 38 C.F.R. §§ 20.302, 20.1103. 2. The evidence received subsequent to the March 2004 rating decision denying service connection for hair loss, a psychiatric disability, and hypertension is new and material, and the claims are reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for hair loss have been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the Appellant in this case, had active duty service from October 1987 to June 1988, December 1990 to June 1991, and April 2002 to August 2002, as well as Reserve/National Guard service from June 1987 to May 2012, with various periods of active duty for training (ADT) and inactive duty for training (IADT). This matter comes before the Board of Veterans’ Appeals (BVA or Board) from a May 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. The Veteran, as well as his wife and daughter, provided testimony at a November 2020 virtual hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims folder. The Board notes that, in a July 2019 rating decision, the RO granted service connection for insomnia and stated that the decision constituted a full grant of the benefits sought on appeal with regard to the claim of entitlement to service connection for a psychiatric disability. However, while psychiatric disorders can manifest sleep impairment, the Board finds that the grant of service connection for insomnia does not constitute a full grant of service connection for all of the symptoms claimed as related to active service by the Veteran or encompassed by the diagnoses of PTSD and/or major depressive disorder. Therefore, the issues of whether new and material evidence has been received to reopen a claim of entitlement to service connection for an acquired psychiatric disability, as well as the underlying issue of entitlement to service connection, remain on appeal. New and Material Evidence 1. New and material evidence having been received, the appeal to reopen the claim of entitlement to service connection for hair loss on face and head (alopecia areata) is granted. 2. New and material evidence having been received, the appeal to reopen the claim of entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD) and major depressive disorder, is granted. 3. New and material evidence having been received, the appeal to reopen the claim of entitlement to service connection for hypertension is granted. In August 2003, the Veteran filed an initial claim for service connection for hair loss, a psychiatric disability, and hypertension. The claim was denied in a March 2004 rating decision, in which the RO found no evidence of a medical nexus between the claimed hypertension and active service, no evidence of a chronic condition manifested by hair loss, and no evidence of an in-service stressor or diagnosis of PTSD. The Veteran did not file a timely notice of disagreement (NOD), and no evidence was received within one year of the March 2004 rating decision, nor were new, relevant service records received at any time thereafter. 38 C.F.R. § 3.156(b) and 3.156(c). Consequently, the March 2004 rating decision became final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. In May 2013, the Veteran filed a request to reopen his claim of entitlement to service connection for hair loss, a psychiatric disability, and hypertension. In the May 2014 rating decision on appeal, the RO denied reopening of the claim of entitlement to service connection for hair loss, and reopened the psychiatric disability and hypertension claims, denying them on the merits. Based on the procedural history outlined above, the issue for consideration with respect to the Veteran’s claims is whether new and material evidence has been received to reopen the claims of entitlement to service connection for hair loss, a psychiatric disability, and hypertension. Evidence added to the record since the time of the last final denial of the hair loss claim in March 2004 includes a favorable nexus opinion provided in the November 2017 VA examination report. With regard to the psychiatric disability, subsequent to the last final denial, the Veteran provided detailed information regarding his claimed in-service stressors, and his stressors were corroborated by the Joint Services Records Research Center (JSRRC). Finally, with regard to the claimed hypertension, the Veteran testified at the November 2020 Board hearing that although he began experiencing symptoms of hypertension while he was deployed, he did not seek treatment for same until after his return home from deployment as he was in a combat situation. The Board finds that this evidence constitutes new and material evidence as it tends to support a medical nexus between the claimed disabilities and active service, which was the basis for the previous denial of the claims. In this regard, the Board notes that the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Therefore, the Board finds that the evidence added to the record since the last final March 2004 denial of the hair loss, psychiatric disability, and hypertension claims constitutes new and material evidence, and that the criteria under 38 C.F.R. § 3.156(a) have been satisfied; therefore, the claims of entitlement to service connection for hair loss, a psychiatric disability, and hypertension are reopened. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). 4. Service connection for hair loss on face and head (alopecia areata) is granted. The Veteran contends that he began experiencing hair loss on his face and head during active service in the early 1990s, when he was stationed in Saudi Arabia. For the reasons discussed below, the Board finds that service connection for hair loss is warranted. Private treatment records from February 1992 show that the Veteran began treatment for loss of facial hair and was diagnosed with alopecia areata. At the time, he reported loss of facial hair over the past several months. He was prescribed Rogaine. Private treatment records from December 1995 indicate that the hair loss had returned in the scalp area, and he was referred to a dermatologist. In January 1996, he reported that he was treated for hair loss that was thought to be stress related. In August 2003, when the Veteran filed his initial claim of entitlement to service connection for hair loss, he stated that he had experienced continuous symptoms of hair loss since returning from the Gulf War. The Veteran was afforded a VA skin examination in November 2017. The examiner diagnosed alopecia, first diagnosed in 1991. The Veteran reported that, at that time, he was treated with intralesional steroids. The examiner opined that the condition was at least as likely as not incurred in or caused by active service, clarifying in a July 2018 addendum that it was not due to any specific exposure, but that it began during his active service. Based on a review of lay and medical evidence of record, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s hair loss began during a period of active service. The Board acknowledges that the VA examiner’s favorable nexus opinion is based on the history provided to him by the Veteran of symptoms beginning in 1991, during active service. However, there is no reason to doubt the credibility of the Veteran’s statements, and, indeed, his statements are corroborated by private treatment records from 1992 which indicate that the hair loss had begun prior to his initial treatment in February 1992 for the same. The Veteran is competent to describe his hair loss, and the Board finds that his statements to the effect that his hair loss began during a period of active service (December 1990 to June 1991) are credible. Moreover, it is reasonable that he would not seek treatment for hair loss when deployed in Southwest Asia. Resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for hair loss is warranted. REASONS FOR REMAND 1. The claim of entitlement to service connection for a right knee disability is remanded. 2. The claim of entitlement to service connection for a left knee disability is remanded. The Veteran contends that he has a right knee disability that was either aggravated or caused by active service, and that his left knee disability was caused by active service. Specifically, at the 2020 Board hearing, he stated that as an aircraft mechanic, he often had to kneel on hard metal surfaces in the cockpits of the aircraft, and that, over the course of 25 years, the cumulative trauma from kneeling caused the current disabilities. Pre-service treatment records from July 1983 show that the Veteran underwent a right knee meniscectomy for internal derangement of the right knee with a peripheral bucket handle tear of the medial meniscus following a basketball injury. At the May 1987 enlistment examination, the clinician noted the pre-service arthroscopy and meniscectomy of the right knee and that there were no complications or sequelae. The Veteran had an orthopedic consultation on the same date as the enlistment examination in May 1987. The orthopedic consultation for the right knee indicated that the Veteran had a right medial meniscectomy in 1983 following a basketball injury. He reported no problems with the knee since then and was back at playing sports with no problems. On physical examination, the right knee had dual medial scars. He had full range of motion with no effusion or tenderness. Negative McMurray’s, and the ligaments were stable. X-rays were negative. Impression was post-operative medial meniscectomy with excellent results, and the Veteran was found fit for military duty. In April 1991, the Veteran had a small wart excised from the left knee and was given an orthopedic brace and told to keep the knee immobilized until he returned to the clinic the following day. The treatment note from the following day indicates no problems with the knee. Private tx records of Dr. M.J., M.D. from October 1994 indicate that the Veteran had acute onset of left knee pain with no associated trauma. He was very active and played sports. On physical examination, the left knee had erythema and swelling in the prepatellar area. There was no intraarticular effusion, and no varus or valgus instability. No abnormality on x-ray. The doctor diagnosed pyogenic prepatellar bursitis. The Veteran was placed on medication, and the doctor told him that if it got worse, he would need hospitalization and possibly surgery. The following week, there was marked improvement in erythema, swelling, and temperature down in the left knee. The Veteran was told to stay on antibiotics for another week and Dr. M.J. would see him as needed. A January 2012 service treatment record indicates that “[k]nee swelling controlled via medications as needed,” but does not indicate which knee was involved nor describe the history of knee swelling. In an August 2019 letter, the Veteran stated that his left knee problems began during Desert Storm deployment in April 1991, when he had a growth removed from the left knee. He further stated that the constant going up and down aircraft ladders, kneeling, and sitting in cockpits caused chronic inflammation of the left knee, and that he was given a brace to relieve the swelling and assist the support of the left knee. At the 2020 Board hearing, the Veteran stated that an orthopedist had recommended a left knee replacement, but these treatment records are not associated with the claims file. The Board finds that a remand is necessary to obtain any and all private treatment records pertaining to treatment for the right and left knee disorders. Moreover, given the documentation of knee problems in the Veteran’s Reserve/National Guard treatment records, the Veteran should be afforded a VA examination to determine the nature of the current knee disorders as well as to obtain a nexus opinion regarding whether the right and left knee disorders were incurred during a period of active service. 3. The claim of entitlement to service connection for an acquired psychiatric disability, to include PTSD and major depressive disorder, is remanded. The Veteran was afforded a VA PTSD examination in April 2014. The examiner diagnosed major depressive disorder in addition to insomnia and opined that the depressive disorder most likely had its onset during the Veteran’s National Guard/Reserve service in the late 1990s, but not during an active duty period. At the 2020 Board hearing, the Veteran testified that his now service-connected insomnia may have caused or aggravated his depressive disorder. The Board finds that a VA examination is necessary to address this question. 4. The claim of entitlement to service connection for hypertension is remanded. The Veteran was diagnosed with hypertension in approximately 1995, according to an October 2000 report from the Veteran’s primary care physician which indicates that he had hypertension of five years’ duration. The first documentation of hypertension is a June 1999 Annual Medical Certificate which indicated that the Veteran reported being seen by a physician for high blood pressure and taking medication for same. The Veteran was afforded a VA examination in April 2014, and the examiner opined that the hypertension had a clear and specific etiology and diagnosis, and that it was not related to a specific exposure event during active service. However, in his January 2017 VA Form 9, the Veteran stated that he believed his hypertension was aggravated by his claimed psychiatric disability, and in the August 2019 VA 646, his representative stated that the hypertension was secondary to his now service-connected insomnia. The Board finds that a VA examination is necessary to address the question of whether the Veteran’s hypertension was caused or aggravated by his service-connected insomnia or by any psychiatric disability. The matters are REMANDED for the following action: 1. Provide the Veteran with the appropriate release form(s) necessary to request any and all private treatment records pertaining to treatment for the right and left knee disorders. All attempts to procure the records should be documented in the file. If any records cannot be obtained, any negative responses should be associated with the claims file, and the Veteran and his representative should be notified of unsuccessful attempts to obtain the records, in order to allow the Veteran the opportunity to obtain and submit those records for review. 2. Afford the Veteran the opportunity to attend a VA examination with an appropriate specialist to address the nature and etiology of his bilateral knee disorders. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished, and a rationale for any opinion expressed should be provided. The claims file must be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such review was accomplished. (a.) The examiner should first identify any and all current right and left knee disorders. (b.) Next, for each diagnosed knee disorder, the examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran’s right and left knee disorders were incurred during or caused by active service? The examiner should discuss the pre-service 1983 private treatment records showing a right knee meniscectomy, as well as the 1991 and 1994 treatment records showing left knee problems, and the 2012 treatment note showing knee swelling. The examiner should also consider the Veteran’s contention that many years of kneeling, climbing ladders, and sitting in the cockpit of aircraft during his Reserve service led to his current knee disorders in reaching his/her conclusion. Note: The term “at least as likely as not” does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 3. Afford the Veteran the opportunity to attend a VA examination with an appropriate specialist regarding the question of whether the claimed psychiatric disability was caused or aggravated by the service-connected insomnia. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished, and a rationale for any opinion expressed should be provided. The claims file, including a copy of this decision, must be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such review was accomplished. (a.) The examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran’s current psychiatric disorder was caused or aggravated by the service-connected insomnia? Note: The term “at least as likely as not” does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. Note: The term “aggravated” in the above context refers to a permanent worsening of the pre-existing or underlying condition, as contrasted to temporary or intermittent flare-ups of symptoms which resolve with return to the previous baseline level of disability. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 4. Afford the Veteran the opportunity to attend a VA examination with an appropriate specialist regarding the question of whether his hypertension was caused or aggravated by the service-connected insomnia or by any psychiatric disability. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished, and a rationale for any opinion expressed should be provided. The claims file, including a copy of this decision, must be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such review was accomplished. (a.) The examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran’s current hypertension was caused or aggravated by the service-connected insomnia or by a psychiatric disability? Note: The term “at least as likely as not” does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. Note: The term “aggravated” in the above context refers to a permanent worsening of the pre-existing or underlying condition, as contrasted to temporary or intermittent flare-ups of symptoms which resolve with return to the previous baseline level of disability. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. Cynthia M. Bruce Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Sherrard, 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.