Citation Nr: 21014187 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 15-29 790 DATE: March 11, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected ischemic heart disease and/or posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from March 1969 to March 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2012 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In April 2017, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge. The appeal was remanded for further development in August 2018 and May 2020. Unfortunately, another remand is required. Pursuant to the Board’s May 2020 remand directives addendum opinions were obtained in November 2020. The Board asked the examiner to opine on whether it is at least as likely as not (50 percent or greater probability) that diagnosed hypertension: (i) had its onset in service or is otherwise related to service, to include as a result of a stressful incident during service when the Veteran was fearful that he was going to be killed an/or conceded exposure to herbicide agents therein. In addressing this question, the examiner was asked to please discuss the 2018 NAS findings of “sufficient evidence of an association” between herbicide agent exposure and hypertension and to please also consider the Veteran’s reports of continuous high blood pressure problems since service, and do not rely on the lack of objective documented treatment in your opinion. (ii) is proximately due to his service-connected ischemic heart disease; (iii) has been aggravated (worsened beyond natural progression) by his service-connected ischemic heart disease; (iv) is proximately due to his service-connected PTSD; or (v) has been aggravated (worsened beyond natural progression) by his service-connected PTSD. In addressing this question, the examiner was asked to comment on the Veteran’s statement that when his PTSD flares up, his blood pressure also goes up. In rendering secondary service connection opinions, the Board instructed the examiner to note that inquiries (ii) – (v) require separate opinions: one for proximate causation and another for aggravation for both ischemic heart disease and PTSD, and a rationale must be provided for each opinion. However, in rendering the direct opinion, the examiner failed to address the Veteran’s statement regarding a stressful incident in service where he feared being killed, his conceded exposure to herbicide agents, the 2018 NAS findings of “sufficient evidence of an association” between herbicide agent exposure and hypertension, and the Veteran’s reports of continuous high blood pressure problems since service, as specifically requested by the Board. Additionally, regarding secondary opinions for hypertension in relation to ischemic heart disease and PTSD, the examiner provides the same negative opinion for both proximate causation and aggravation and fails to address the Veteran’s statement that when his PTSD flares up, his blood pressure goes up, as specifically requested by the Board. The examiner also imposes a temporal element to secondary service connection when there is no such temporal restriction in the regulation for secondary service connection. Frost v. Shulkin, 29 Vet. App. 131 (2017). Thus, these opinions are inadequate, and an addendum opinion is needed from a different examiner to ensure substantial compliance with the Board’s May 2020 remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Any outstanding treatment records should also be secured. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records. 2. With any necessary assistance from the Veteran, obtain any relevant outstanding private treatment records. 3. Then, obtain an addendum opinion from an examiner other than the January 2020 and November 2020 examiners that addresses the etiology of the Veteran’s hypertension. The claims file, to include a copy of this remand, must be made available to the examiner for review, and the examination report must reflect that such a review was accomplished. No additional examination of the Veteran is necessary, unless the examiner determines otherwise. Following a review of the claims file, the examiner should opine on the following: (i) Is it at least as likely as not (50 percent or greater probability) that diagnosed hypertension (see January 2020 VA examination report) had its onset in service or is otherwise related to service, to include as a result of a stressful incident during service when the Veteran was fearful that he was going to be killed an/or conceded exposure to herbicide agents therein? See April 2017 Board Hearing Transcript at 15. In addressing this question, please address the Veteran’s presumed exposure to herbicide agents, do not rely on the lack of availability of presumptive service connection for hypertension, and please discuss the National Academy of Sciences Institute of Medicine’s conclusion that there is “sufficient evidence of an association” between herbicide exposure and hypertension. See NAS, Veterans & Agent Orange: Update 11 (2018). According to NAS, “[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide agent exposure. Please also consider the Veteran’s reports of continuous high blood pressure problems since service and determine whether a nexus to service is medically plausible based on the same, and do not rely on the lack of objective documented treatment in your opinion. While true the Veteran cannot diagnose hypertension or opine as to its etiology, he is competent to report continuous hypertension symptoms since service separation, and this information should be considered in rendering an opinion. (ii) Is at least as likely as not (50 percent or greater) that the Veteran’s hypertension: (1) is proximately due to his service-connected ischemic heart disease; (2) has been aggravated (worsened beyond natural progression) by his service-connected ischemic heart disease; (3) is proximately due to his service-connected PTSD; or (4) has been aggravated (worsened beyond natural progression) by his service-connected PTSD. The examiner should also comment on the Veteran’s statement that when his PTSD flares up, his blood pressure also goes up. See April 2017 Board Hearing Transcript at 17. In addressing these questions, all relevant lay evidence must be considered. Please note that under applicable legislation and VA requirements, obesity is not a disease or disability, but it may act as an “intermediate step” between a service-connected disability and a current disability that may be service-connected on a secondary basis. To determine whether any weight gain or obesity is an “intermediate step” between either the Veteran’s service-connected ischemic heart disease and PTSD and hypertension, the examiner should fully answer the above questions. The examiner should note that inquires (ii)(1)-(4) require separate opinions: one for proximate causation and one for aggravation, and a separate rationale should be provided for each opinion. Please note that it is not necessary that ischemic heart disease and PTSD be service-connected, or even diagnosed, at the time his hypertension is incurred, and reliance on this fact in support of a negative opinion will render it inadequate. A comprehensive rationale for all opinions must be provided. If an opinion cannot be provided without resorting to speculation, the examiner must explain why this is so and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). S. BUSH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Asante, Ruby 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.