Citation Nr: 21025798 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 12-25 949 DATE: April 29, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD) and/or as due to herbicide exposure, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1968 to October 1975. This matter is 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). The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in March 2017. A transcript of the hearing is associated with the electronic claims file. The Board issued two prior remands on this claim in August 2017 and March 2019. 1. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD and/or as due to herbicide exposure is remanded. In December 2011, the Veteran requested service connection for high blood pressure. The RO issued a July 2012 rating decision denying service connection noting that there was no evidence of a diagnosis within one year of active service. The Veteran appealed this issue up to the Board. On his Form 9 appeal, the Veteran wrote that he did not believe his medical records were looked at completely and contended that his hypertension was a result of his service-connected PTSD medication. The Veteran noted that he did not have hypertension when he got out of the military, but that “all of the problems that I have had with PTSD has caused this problem.” At his Board hearing the Veteran’s representative argued that the Veteran’s prescribed PTSD medication, Wellbutrin, caused a prominent side effect of hypertension. In August 2017, the Board remanded the claim instructing the RO to provide the Veteran with a VA examination for his hypertension and obtain an opinion as to its etiology including any relationship to the Veteran’s service-connected PTSD or the medication prescribed for such. The Veteran was given a VA examination for his hypertension in February 2018. The examiner opined that “review of the current medical literature indicates that PTSD does not cause hypertension.” The examiner went on to explain that there is no evidence of rapid progression of the Veteran’s hypertension due to his PTSD medications because there is no evidence to support that the Veteran’s hypertension has worsened. In fact, the Veteran has been on the same dosage of medication for his hypertension since he was first diagnosed with it in 2009. Finally, the examiner noted that in most cases the exact cause of hypertension is not ever determined but that it is known to become more common with age and in those who are overweight or obese (the examiner pointed out that at the time the Veteran was overweight, but was previously obese), those who are physically inactive, or in those who have a positive family history of hypertension. The Board notes that the Veteran’s DD214 lists service in Vietnam from 7 Jun 70 to 30 Apr 71. Thus, herbicide exposure is presumed. As this theory of entitlement had not previously been considered, in March 2019 the Board issued another remand in order to obtain an addendum opinion regarding such. In November 2019 an addendum opinion was uploaded into the Veteran’s electronic claims file. Here, the examiner opined that it was less likely than not that the Veteran’s hypertension was due to his presumed herbicide exposure. Specifically, the examiner wrote “Veteran was diagnosed with hypertension about 5 years ago at the age of 65. His hypertension is controlled with HCTZ only. He has numerous risk factors for hypertension including his age, activity, chronic alcohol use (fifth every 3 days) and family history.” The examiner went on to discuss the National Academy of Sciences 11/15/18 update moving hypertension to the sufficient category indicating that there was enough epidemiologic evidence to conclude a positive association with herbicide exposure. However, the examiner wrote “The background risk of hypertension (in the absence of herbicide exposure) is still much higher than in this association (72.2% of Vietnam deployed non sprayers and 72.2% of non-Vietnam deployed non sprayers). In addition, there is no compelling evidence in this case that herbicide exposure is casually related to the development in hypertension.” The Board finds that another addendum opinion is necessary. The matters are REMANDED for the following action: 1. Obtain an addendum opinion to the November 2019 addendum opinion. In light of the examiner’s finding that the Veteran “has numerous risk factors for hypertension including his age, activity, chronic alcohol use (fifth every 3 days) and family history,” please opine as to whether it is at least as likely as not that his hypertension was caused by OR aggravated by his service-connected alcohol dependence associated with his service-connected posttraumatic stress disorder. The examiner is requested to provide a clear rationale and explain in detail the underlying reasoning for any opinions expressed. A discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Ruiz, Associate 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.