Citation Nr: 21015935 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 14-25 339 DATE: March 18, 2021 REMANDED Entitlement to service connection for hepatitis C, as secondary to service-connected disability, is remanded. Entitlement to service connection for peripheral artery disease (PAD), as secondary to service-connected disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1968 to October 1970. The Veteran died in January 2012. The appellant is his surviving spouse, who has been substituted in this appeal. See Administrative Decision (May 2012). This appeal comes before the Board of Veterans’ Appeals (Board) from a January 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. In April 2018, March 2020, and July 2020, the case was remanded for additional development. It is again before the Board for appellate review. Service connection - Hepatitis C, PAD In this case, the appellant, and her representative, have not argued direct service connection. The appellant has contended that the Veteran’s hepatitis C and PAD warrant service connection on a secondary basis. The case was remanded most recently in July 2020 in order to obtain a medical opinion on several aspects of the secondary service connection claims. A VA opinion was provided in August 2020 with addendum opinions added in September and October 2020. As will be explained below, the Board finds that these opinions are inadequate. Substance Abuse as Symptom of or Secondary to PTSD The examiner was asked to provide an opinion as to whether the Veteran’s substance abuse was a symptom of or secondary to his service-connected PTSD. If the opinion in that regard was positive, the examiner was then to provide opinions as to whether the Veteran’s hepatitis C or PAD were secondary to substance abuse. In the August 2020 opinion, the examiner did not address the question of whether substance abuse was a symptom of PTSD, as required by the remand. With regard to the opinion on secondary service connection, she opined that substance abuse issues were not likely related or aggravated by his service-connected PTSD, as his substance abuse began prior to entering the military service and before his service connection was granted for PTSD in 2003. The examiner was asked to clarify her opinion as to whether the Veteran’s PTSD aggravated his substance abuse. In a September 2020 addendum opinion, she again stated that the Veteran’s substance abuse had its onset prior to service. She also noted that the Veteran had attended college after returning from Vietnam, retired from General Motors after working for 25 years, and had been married for 16 years to his wife, apparently to show that the Veteran did not have worsening substance abuse problems and therefore would not warrant secondary service connection based on aggravation. The Board finds that this opinion is inadequate as the examiner did not address the evidence in the record showing the Veteran’s substance abuse in the years immediately preceding his death. In the October 2020 addendum opinion, the examiner noted a VA medical record dated in August 2009, reflecting that the Veteran reported his last alcohol use was one year prior to the examination. He had used heroin the week before the examination, reported using it four times within the prior month, and noted that he had been spending $400 to $600 dollars a month for heroin over the prior six months. He reported using cannabis the week before the examination and had been using it since he was 19. An opinion is needed to address whether the Veteran’s PTSD aggravated his substance abuse that addresses the evidence showing substance abuse in the years before his death. Secondary Service Connection – Hepatitis C, PAD Since the examiner did not find that substance abuse was not aggravated by his service-connected PTSD, she did not address the issues of whether the Veteran’s hepatitis C or PAD were secondary to his substance abuse. On remand, if the examiner does find that substance abuse was aggravated by his service-connected PTSD, an opinion must be provided as to whether the Veteran’s substance abuse caused or aggravated his hepatitis C or PAD. The examiner was also to provide opinions as to whether the Veteran’s hepatitis C or PAD was secondary to his service-connected PTSD, lung cancer, or heart disability. Hepatitis C, PAD Secondary to PTSD In the September 2020 opinion, the examiner found that the Veteran’s hepatitis C and PAD were not caused or aggravated by his service-connected PTSD. She provided the rationale that hepatitis C, transmitted through blood contact such as sharing injecting instruments, and PAD, a decrease in arterial blood flow, were not transmitted or caused by having a mental health condition. The examiner noted that IV drug use was a risk factor for both hepatitis C and PAD, but that the Veteran was not service connected for substance abuse. The examiner did not provide a rationale for her opinion that hepatitis C and PAD were not aggravated by his service-connected PTSD. On remand, further opinion is needed with regard to secondary service connection based on aggravation with a rationale for the opinion. Hepatitis C Secondary to Lung Cancer, IHD The August 2020 opinion further reflected the examiner’s opinion that the Veteran’s hepatitis C was not likely related to or aggravated by his lung cancer or IHD. The rationale provided was that the Veteran was diagnosed with lung cancer and IHD after he was diagnosed with hepatitis C; therefore, there was no causal relationship between these health events. The examiner did not provide an opinion or rationale as to whether the Veteran’s hepatitis C was aggravated by his lung cancer or IHD. On remand, further opinion is needed with regard to secondary service connection based on aggravation with a rationale for the opinion. PAD secondary to Lung Cancer, IHD In August 2020, the examiner opined that PAD was less likely than not secondary to the Veteran’s service-connected IHD, as PAD was diagnosed in 2003 but that the Veteran was negative for myocardial ischemia until December 2011. She opined that there was no medical evidence to support the claim that the Veteran’s PVD was secondary to his service-connected lung cancer or his treatment. The examiner provided the opinion that the Veteran’s PAD was related to the Veteran’s long-term smoking. The examiner did not provide an opinion or rationale as to whether the Veteran’s PAD was aggravated by his lung cancer or IHD. On remand, further opinion is needed with regard to secondary service connection based on aggravation with a rationale for the opinion. The matters are REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s hepatitis C and PAD. The medical opinion should, among other things, include a discussion of the documented history and assertions. See, e.g., Correspondence (July 2014). The examiner must provide a thorough rationale for each opinion expressed. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. The opinion must answer the following: A. SUBSTANCE ABUSE (TO INCLUDE ALCOHOL, MARIJUANA, AND HEROIN) (a) Whether any substance abuse is at least as likely as not a symptom of service-connected PTSD. (b) Whether any substance abuse was at least as likely as not aggravated beyond its natural progression by service-connected PTSD. In so opining, the examiner must address the Veteran’s reports of substance abuse in the years preceding his death and the appellant’s statements in the course of this appeal. If the Veteran’s substance abuse was aggravated by his service-connected PTSD, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran and appellant’s statements as to the nature, severity, and frequency of his observable symptoms over time. B. HEPATITIS C (c) If the Veteran is found to have substance abuse etiologically related to service-connected PTSD, then opine on whether his hepatitis C is at least as likely as not aggravated beyond its natural progression by service-connected substance abuse. (d) Whether the Veteran’s hepatitis C is at least as likely as not aggravated beyond its natural progression by service-connected PTSD. (e) Whether the Veteran’s hepatitis C is at least as likely as not aggravated beyond its natural progression by service-connected heart disability. (f) Whether the Veteran’s hepatitis C is at least as likely as not aggravated beyond its natural progression by service-connected lung cancer disability. If the Veteran’s hepatitis C was aggravated by a service-connected disability (substance abuse, if service-connected, PTSD, heart disability, or lung cancer), the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran and appellant’s statements as to the nature, severity, and frequency of his observable symptoms over time. C. PAD (g) If the Veteran is found to have substance abuse etiologically related to service-connected PTSD, then opine on whether his PAD is at least as likely as not aggravated beyond its natural progression by service-connected substance abuse. (h) Whether the Veteran’s PAD is at least as likely as not aggravated beyond its natural progression by service-connected PTSD. (i) Whether the Veteran’s PAD is at least as likely as not aggravated beyond its natural progression by service-connected heart disability. (j) Whether the Veteran’s PAD is at least as likely as not aggravated beyond its natural progression by service-connected lung cancer disability. (Continued on the next page)   If the Veteran’s PAD was aggravated by a service-connected disability (substance abuse, if service-connected, PTSD, heart disability, or lung cancer), the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran and appellant’s statements as to the nature, severity, and frequency of his observable symptoms over time. J. B. FREEMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Harrigan Smith 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.