Citation Nr: 21024563 Decision Date: 04/23/21 Archive Date: 04/23/21 DOCKET NO. 13-30 605 DATE: April 23, 2021 REMANDED Entitlement to service connection for hypertension is remanded. INTRODUCTION The Veteran served on active duty from July 1969 to December 1970, with service in the Republic of Vietnam. In February 2017, the Veteran attended a hearing before the undersigned Veterans Law Judge. A transcript of this hearing is of record. When this case was before the Board in September 2017, March 2019, and October 2020 the above-noted issue was remanded for further development. The case has since been returned for additional appellate review. REASONS FOR REMAND Unfortunately, the Veteran’s claim must again be remanded in order to ensure compliance with the prior Board remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In prior remands, the Board has indicated that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). However, to date, substantial compliance with these Board instructions has not been achieved. When this case was before the Board in September 2017, March 2019, and October 2020, the above-noted issue was remanded in order to obtain a comprehensive medical opinion. In the March 2019 and October 2020 remands, the Board found prior VA examinations to be insufficient because the examiners failed to provide any analysis of the Veteran’s specific facts and circumstances. The Board also found this case requires an examiner to provide a causal inference determination. Such determination requires the examiner to make a judgment; however, that judgment must be supported by Veteran-specific data. In the March 2019 remand, the Board specifically requested an examiner consider all relevant information, such as how many risk factors did/does the Veteran have for hypertension, whether his PTSD was a particularly strong risk factor, the amount of time he has experienced stress, and the severity of his stress. After considering all procurable information and factors, the examiner was asked to provide an opinion as to whether any degree of the Veteran’s hypertension was as likely as not caused by his service-connected PTSD. During a December 2019 VA examination, the examiner acknowledged a growing body of research which shows PTSD may be linked to hypertension, and that hypertension can be aggravated by PTSD. However, the examiner erroneously concluded that since the Veteran’s PTSD and hypertension were both diagnosed in 2011, this “supports a negative opinion.” The Board found this opinion to be insufficient, because the examiner failed to acknowledge the Veteran’s extensive history of treatment for his psychiatric disorder, which include an inpatient hospitalization in 1971, as well as a diagnosis of PTSD dating to 1999. The RO obtained a third medical opinion in November 2020 from a Gynecologist. In sum, the examiner found “PTSD and other psychological comorbidities do not cause essential hypertension. This is medical fact.” The examiner went on to state this “also applies to aggravation.” The examiner wholly failed to acknowledge or discuss the prior medical recognitions made by the December 2019 examiner—specifically—that PTSD may be linked to hypertension. As previously explained, to be considered adequate, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Following the November 2020 medical opinion, the Veteran’s representative provided a brief in support of the Veteran’s claim. In the April 2021 memorandum, the representative provided numerous citations to medical treatises and journal articles, which the representative purports establish a link between hypertension and psychiatric disorders. Based on the foregoing insufficiencies, the Board finds substantial compliance with the prior remands has not been achieved. As such, the Board finds an addendum medical opinion from a circulatory disease specialist is necessary prior to final adjudication of this matter. Accordingly, the case is REMANDED for the following action: 1. Obtain an addendum medical opinion from a physician who specializes in circulatory diseases to comment on the etiology of the Veteran’s hypertension. All pertinent evidence of record should be made available to and reviewed by the examiner. A new examination should only be conducted if deemed necessary by the examiner. Following a review of the record, the examiner should state whether any degree of the Veteran’s hypertension at least as likely as not (a 50 percent probability or greater): a) originated during his period of active service or is otherwise etiologically related to his active service; b) was caused by his service-connected PTSD; or c) was worsened to any degree by his service-connected PTSD. In this respect, the examiner must accurately consider all procurable facts such as how many risk factors did/does the Veteran have for hypertension, whether his PTSD was a particularly strong risk factor, the amount of time he has experienced stress, and the severity of his stress. The examiner should also consider and discuss both the December 2019 VA examiner’s findings, which indicated a growing body of research which shows PTSD may be linked to hypertension. Further, the examiner must also consider and expressly discuss the medical treatises and medical journal articles cited to by the Veteran’s representative in the April 2021 brief, which purport to establish a link between psychiatric disorders and hypertension. Only after considering all procurable information and factors, should the examiner provide an opinion as to whether the Veteran’s hypertension is consequentially related to his service-connected PTSD. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Fraser, 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.