Citation Nr: 21028302 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 17-25 190 DATE: May 10, 2021 ORDER New and material evidence having been received, the application to reopen the previously denied claim of service connection for hypertension is granted. New and material evidence having been received, the application to reopen the previously denied claim of service connection for coronary artery disease is granted. Service connection for post-traumatic stress disorder (PTSD) is granted. Service connection for obstructive sleep apnea as secondary to service-connected PTSD is granted. Service connection for hypertension as secondary to service-connected PTSD is granted. Service connection for headaches as secondary to service-connected PTSD and hypertension is granted. Service connection for cerebrovascular accident as secondary to service-connected PTSD and hypertension is granted. Service connection for coronary artery disease as secondary to service-connected PTSD and hypertension is granted. FINDINGS OF FACT 1. A September 1997 rating decision denying a claim for service connection for hypertension was not timely appealed and became final; evidence received since that time (including a December 2020 private medical opinion which indicates that the Veteran's hypertension is causally related to his multiple mental health symptoms) relates to an unestablished fact necessary to substantiate the claim and raises a reasonable possibility of substantiating the claim. 2. A May 2013 rating decision denying a claim for service connection for coronary artery disease was not timely appealed and became final; evidence received since that time (including a December 2020 private medical opinion which indicates that the Veteran's coronary artery disease is causally related to his multiple mental health symptoms) relates to an unestablished fact necessary to substantiate the claim and raises a reasonable possibility of substantiating the claim. 3. The probative evidence of record including an October 2018 VA examiner's opinion, a December 2020 private examiner's opinion and the Veteran's own statements indicate that the Veteran's diagnosed PTSD is causally related to traumatic events he witnessed during service. 4. A June 2019 VA treatment note indicates that the Veteran has a diagnosis of obstructive sleep apnea. The probative evidence of record including a December 2020 private examiner's opinion indicates that the Veteran's obstructive sleep apnea is causally related to his service-connected PTSD. 5. A July 1997 VA treatment record indicates that the Veteran has a history of hypertension. The probative evidence of record including a December 2020 private examiner's opinion indicates that the Veteran's hypertension is causally related to his service-connected PTSD. 6. A July 2017 VA treatment note indicates that the Veteran has headaches intermittently in the right occipital region. The probative evidence of record including a December 2020 private examiner's opinion indicates that the Veteran's headaches are causally related to his service-connected PTSD and hypertension. 7. The Veteran suffered a cerebrovascular accident in 1995. The probative evidence of record including a December 2020 private examiner's opinion indicates that the Veteran's cerebrovascular accident is causally related to his service-connected PTSD and hypertension. 8. The Veteran has a history of coronary artery disease dating back to at least July 1997. The probative evidence of record including a December 2020 private examiner's opinion indicates that the Veteran's coronary artery disease is causally related to his service-connected PTSD and hypertension. CONCLUSIONS OF LAW 1. New and material evidence has been received to warrant reopening of the claim of service connection for hypertension. 38 U.S.C. § 5107, 5108; 38 C.F.R. § 3.156. 2. New and material evidence has been received to warrant reopening of the claim of service connection for coronary artery disease. 38 U.S.C. § 5107, 5108; 38 C.F.R. § 3.156 3. The criteria for service connection for PTSD have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for obstructive sleep apnea as secondary to service-connected PTSD have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for service connection for hypertension as secondary to service-connected PTSD have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. The criteria for service connection for headaches as secondary to service-connected PTSD and hypertension have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 7. The criteria for service connection for cerebrovascular accident as secondary to service-connected PTSD and hypertension have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 8. The criteria for service connection for coronary artery disease as secondary to service-connected PTSD and hypertension have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service with the United States Army from April 1980 to March 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from August 2015 and August 2016 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). These matters were before the Board in July 2019 and were remanded for further development. New and Material Evidence Legal Criteria As a threshold matter, the Board must determine if new and material evidence has been submitted to reopen a previously denied claim. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001) (reopening after a prior unappealed RO denial). A rating decision becomes final when it has not been appealed within the prescribed period and when no additional material evidence was received within a year of the decision; the decision is not subject to revision on the same factual basis. 38 U.S.C. § 7105(b); 38 C.F.R. §§ 3.104, 20.302, 20.1103. To reopen a claim, "new and material evidence" must be added to the record. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decisionmakers. To be considered "material," the evidence must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). This means that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence must be added to the record since the time that the claims were finally disallowed on any basis (that is, including a denial of reopening) not only since the time the claims were last disallowed on the merits. See Evans v. Brown, 9 Vet. App. 273, 285 (1996). Regardless of the RO's determination as to whether new and material evidence has been received, the Board has a jurisdictional responsibility to determine whether a claim previously denied by the RO has been properly reopened. See Jackson v. Principi, 265 F.2d 1366 (Fed. Cir. 2001) (citing 38 U.S.C.A. § § 5108, 7105(c)). New and material evidence having been received, the application to reopen the previously denied claim of service connection for hypertension is granted. Factual Background In September 1997, the RO denied the Veteran's claim for service connection for a hypertension because his condition was neither incurred in nor caused by service. The AOJ explained that the Veteran did not indicate treatment for hypertension since discharge from service until 1992. The Veteran did not perfect his appeal or submit new and material evidence within one year of the decision; therefore, the decision became final. The Veteran submitted a December 2020 private medical opinion which indicates that the Veteran's hypertension is causally related to his multiple mental health symptoms. Analysis The post-decision private medical opinion constitutes "new" evidence because it was not previously submitted to agency decisionmakers. The Board finds that the private physician's positive nexus opinion is material and therefore are sufficient to reopen the claim for service connection for hypertension. For evidence to be material in this matter it would have to be evidence that would tend to show that the Veteran's hypertension is causally related to service or service-connected conditions. 38 C.F.R. § 3.156(a). The new evidence suggests that the Veteran's hypertension is causally related to his mental health conditions. As indicated above, the Board is granting service connection for PTSD. Therefore, the additional evidence received is both new and material, and the claim for service connection for hypertension may be reopened. 38 U.S.C. § 5108. New and material evidence having been received, the application to reopen the previously denied claim of service connection for coronary artery disease is granted. Factual Background In May 2013, the RO denied the Veteran's claim for service connection for coronary artery disease as secondary to hypertension because his hypertension was not causally related to service. The Veteran did not perfect his appeal or submit new and material evidence within one year of the decision; therefore, the decision became final. The Veteran submitted a December 2020 private medical opinion which indicates that the Veteran's coronary artery disease is causally related to his multiple mental health symptoms. The private medical opinion also indicated that the Veteran's coronary artery disease was related to his hypertension. Analysis The post-decision private medical opinion constitutes "new" evidence because it was not previously submitted to agency decisionmakers. The Board finds that the private physician's positive nexus opinion is material and therefore are sufficient to reopen the claim for service connection for coronary artery disease. For evidence to be material in this matter it would have to be evidence that would tend to show that the Veteran's coronary artery disease is causally related to service or service-connected conditions. 38 C.F.R. § 3.156(a). The new evidence suggests that the Veteran's coronary artery disease is causally related to his mental health conditions. As indicated above, the Board is granting service connection for PTSD. Therefore, the additional evidence received is both new and material, and the claim for service connection for coronary artery disease may be reopened. 38 U.S.C. § 5108. Service Connection Legal Criteria Service connection may be granted for a disability due to a disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303. To substantiate a claim of service connection there must be evidence of: (1) a present disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). "Secondary" service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected condition. 38 C.F.R. § 3.310. 1. Service connection for PTSD is granted. Factual Background The evidence of record indicates that he had a diagnosis of PTSD manifesting itself in schizoaffective symptoms and alcohol and drug use. See May 2014 VA treatment record. The Veteran reported in a July 2015 statement that while he was on border patrol in Germany, he saw the decapitated corpses of two fellow servicemembers. The Veteran also reported that he had to bag an amputated hand of a German woman who was captured by Russian guards. The Veteran reported in a separate statement that he witnessed the decapitation of a fellow servicemember after a helicopter accident. The Veteran provided an August 2018 buddy statement from his cousin who reported that prior to joining the military, the Veteran was healthy and happy. The Veteran's cousin reported that the Veteran became more isolated and began using drugs after he returned from the military. The provided the results of an October 2018 private medical examination which indicated that the Veteran's mental health issues began in service and that he began having trouble sleeping, hallucinations and depression. The physician opined that the Veteran's PTSD more likely than not began during service and continued interrupted until the present. The physician cited medical treatises in support of their opinion. At a March 2020 VA examination the conducting physician opined that it was at least as likely as not that the Veteran's PTSD was causally related to his service. As a rationale, the physician indicated that there was no indication that the Veteran had a mental health issue prior to joining the military and that he clearly has a current diagnosis of PTSD. The physician explained that the Veteran appears to be a reliable historian and reported witnessing getting their throats slashed at the border in Germany. The physician opined that it is at least as likely as not that the Veteran's mental issues are secondary or were precipitated by this event. Analysis The evidence of record indicates that the Veteran has a diagnosis of PTSD. The Board finds that the Veteran is competent and credible to describe the traumatic events he witnessed during service. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). What remains for consideration is whether the Veteran's PTSD is causally related to his service. The Board assigns probative value to the October 2018 private examiner's opinion that the Veteran's PTSD began during service and has continued since then because they supported their opinion with a rationale and cited medical treatises to support their opinion. The Board also assigns probative value to the March 2020 VA examiner's opinion that the Veteran's PTSD is causally related to his service because they supported their opinion with a rationale and indicated that they had reviewed the claims file. Accordingly, the Board finds that the preponderance of the evidence is in favor of a finding that the Veteran's diagnosed PTSD is causally related to his service. 2. Service connection for obstructive sleep apnea as secondary to service-connected PTSD is granted. Factual Background The evidence of record indicates that the Veteran has a diagnosis of obstructive sleep apnea. See June 2019 VA treatment note. The Veteran submitted the results of a December 2020 private medical treatment during which the conducting physician opined that it was at least as likely as not that the Veteran's obstructive sleep apnea was causally related to his mental health conditions. As a rationale, the physician explained that the Veteran reported that he is extremely vigilant and experiences racing thoughts when trying to sleep. The physician further explained that research has shown that psychiatric disorders are commonly associated with obstructive sleep apnea. The physician cited a study which indicated frequent awakenings lead to fragmented sleep which results in less time spent in deep sleep and REM sleep which are the most physically and mentally restorative stages of sleep. The physician also noted that the Veteran is prescribed sedative medication which can suppress the central nervous system resulting in a reduction in carbon dioxide responsiveness. Analysis The evidence of record indicates that the Veteran has a diagnosis of obstructive sleep apnea. What remains for consideration is whether the Veteran's obstructive sleep apnea is causally related to his service-connected PTSD. The Board assigns probative value to the December 2020 private physician's opinion that the Veteran's obstructive sleep apnea is causally related to his mental health disorders because they supported their opinion with a rationale, indicated that they reviewed the claims file and cited medical treatises to support their opinion. Accordingly, the Board finds that the preponderance of the evidence is in favor of a finding that the Veteran's diagnosed obstructive sleep apnea is causally related to his service-connected PTSD. 3. Service connection for hypertension as secondary to service-connected PTSD is granted Factual Background The Veteran has a history of hypertension dating back to at least July 1997. See VA treatment record. The Veteran submitted the results of a December 2020 private medical treatment during which the conducting physician opined that it was at least as likely as not that the Veteran's hypertension was causally related to his mental health conditions. As a rationale, the physician explained that research has shown that anxiety and depression are predictive of later incidence of hypertension and prescription treatment. The physician also cited a study which found the incidence rate of hypertension was higher in persons with high or intermediate anxiety symptom scores than in persons with low anxiety symptoms scores. Analysis The evidence of record indicates that the Veteran has a diagnosis of hypertension. What remains for consideration is whether the Veteran's hypertension is causally related to his service-connected PTSD. The Board assigns probative value to the December 2020 private physician's opinion that the Veteran's hypertension is causally related to his mental health disorders because they supported their opinion with a rationale, indicated that they reviewed the claims file and cited medical treatises to support their opinion. Accordingly, the Board finds that the preponderance of the evidence is in favor of a finding that the Veteran's diagnosed hypertension is causally related to his service-connected PTSD. 4. Service connection for headaches as secondary to service-connected PTSD and hypertension is granted. Factual Background The Veteran sought treatment for "pounding headaches" which he rated at 9/10. See December 2015 VA treatment record. A July 2017 VA treatment note indicates that the Veteran has headaches intermittently in the right occipital region. The Veteran reports that he has headaches nearly every day due to an escalation of mental health symptoms that will cause a combination of symptoms including disturbed concentration, blurred vision, dizziness, nausea, and light and sound sensitivity. The Veteran also reported that when his headaches become severe, he has to lay down in a dark quiet area for up to four hours depending on the severity of his headache. The Veteran submitted the results of a December 2020 private medical treatment during which the conducting physician opined that it was at least as likely as not that the Veteran's headaches are caused by his diagnosed mental health conditions and hypertension. As a rationale, the physician explained that hypertension is a known contributor to chronic headaches. The physician cited a medical treatise which indicates that hypertension is one of the factors leading to the exacerbation of the frequency and severity of attacks both in migraine and tension-type headaches. The physician cited an additional study which showed that anxiety and depression facilitate the onset of headaches and that patients with chronic headache pain present with high levels of anxiety and depressive symptomatology. The physician also cited a medical treatise which indicates that psychological stress can be a predisposing factor that contributes to headache disorder onset, exacerbate individual headache episodes and accelerate the progression of a headache disorder into a chronic condition. Finally, the physician reported that the Veteran indicated that stress is a constant source of headache pain for him. Analysis The evidence of record indicates that the Veteran has a diagnosis of headaches. What remains for consideration is whether the Veteran's headaches are causally related to his service-connected PTSD and hypertension. The Board assigns probative value to the December 2020 private physician's opinion that the Veteran's headaches are causally related to his mental health disorders and hypertension because they supported their opinion with a rationale, indicated that they reviewed the claims file and cited medical treatises to support their opinion. Accordingly, the Board finds that the preponderance of the evidence is in favor of a finding that the Veteran's diagnosed headaches are causally related to his service-connected PTSD and hypertension. 5. Service connection for cerebrovascular accident is granted. Factual Background The Veteran suffered a cerebrovascular accident in 1995. See VA treatment record. The Veteran submitted the results of a December 2020 private medical treatment during which the conducting physician opined that it was at least as likely as not that the Veteran's cerebrovascular accident was causally related to his mental health conditions and hypertension. As a rationale, the physician explained that based on the information within the records, it is very likely that the Veteran suffered from hypertension many years prior to the 1997 diagnosis. The physician cited a medical study which indicated that high blood pressure damages arteries throughout the body, creating conditions where they can burst or clog more easily. The study indicates that weakened arteries in the brain, resulting from high blood pressure, put an individual at a much higher risk for a cerebrovascular accident. The medical study also indicated that severe emotional distress negatively impacts an individual's overall health and well-being and extreme stress induces the same biochemical change that cause stroke damage in the brain including the release of bodily toxins and oxidative stress. The physician cited a recent nationwide longitudinal medical study showing that individuals with anxiety disorders have an increased risk of developing a cerebrovascular accident. Analysis The evidence of record indicates that the Veteran underwent a cerebrovascular accident. What remains for consideration is whether the Veteran's cerebrovascular accident was causally related to his service-connected conditions to include his PTSD and hypertension. The Board assigns probative value to the December 2020 private physician's opinion that the Veteran's cerebrovascular accident was causally related to his hypertension and mental health disorders because they supported their opinion with a rationale, indicated that they reviewed the claims file and cited medical treatises to support their opinion. Accordingly, the Board finds that the preponderance of the evidence is in favor of a finding that the Veteran's diagnosed cerebrovascular accident is causally related to his service-connected PTSD and hypertension. 6. Service connection for a coronary artery disease is granted. Factual Background The Veteran has a history of coronary artery disease dating back to at least July 1997. See VA treatment record. The Veteran submitted the results of a December 2020 private medical treatment during which the conducting physician opined that it was at least as likely as not that the Veteran's coronary artery disease was causally related to his mental health conditions and hypertension. As a rationale, the physician explained that there are several risk factors for coronary artery disease including depression and hypertension. The physician cited medical literature which indicates that depression is common with patients with coronary artery disease and that the date is consistent in supporting that depression is a risk factor for both the development and worsening of coronary artery disease. The physician cited an additional article which indicates that the association of hypertension and coronary artery disease is well-established. Analysis The evidence of record indicates that the Veteran has a diagnosis of coronary artery disease. What remains for consideration is whether the Veteran's coronary artery disease was causally related to his service-connected conditions to include his PTSD and hypertension. The Board assigns probative value to the December 2020 private physician's opinion that the Veteran's coronary artery disease was causally related to his hypertension and mental health disorders because they supported their opinion with a rationale, indicated that they reviewed the claims file and cited medical treatises to support their opinion. Accordingly, the Board finds that the preponderance of the evidence is in favor of a finding that the Veteran's diagnosed coronary artery disease is causally related to his service-connected PTSD and hypertension. VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Alexander Bahus 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.