Citation Nr: 21029330 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 13-24 325 DATE: May 13, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus and/or posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for a skin disorder (claimed as multiple lipomas), to include as secondary to service-connected diabetes mellitus, PTSD, and herbicide exposure is remanded. REASONS FOR REMAND The Veteran served as a member of the United States Air Force, with active duty service from May 1968 through April 1972. The Veteran testified at a hearing on appeal before the undersigned in January 2017. A transcript is of record. In November 2017, the Board remanded the Veteran's appeal for evidentiary development. In October 2019, the Board denied the Veteran's appeal. A June 2020 Court of Appeals for Veterans Claims (Court) order vacated the Board's decision with respect to these issues, and adopted a Joint Motion for Partial Remand (JMPR) for reconsideration of the Veteran's claim. The Court noted that the portions of the Board's decision that denied service connection for chronic fatigue syndrome, memory loss, a right lung disorder, a urinary bladder disorder, and a bilateral kidney disorder, were to remain undisturbed. In October 2020, the Board remanded the appeal for additional development. It has since been returned to the Board for further consideration. 1. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus and/or posttraumatic stress disorder (PTSD) is remanded. 2. Entitlement to service connection for a skin disorder (claimed as multiple lipomas), to include as secondary to service-connected diabetes mellitus, PTSD, and herbicide exposure is remanded. As discussed previously, in June 2020, the Court issued a JMPR vacating and remanding the issues of entitlement to service connection for hypertension and a skin disorder for additional action. Specifically, the Court found that the Board failed to ensure the duty to assist was satisfied by obtaining an adequate medical opinion. Historically, in November 2017, the Board remanded the issues of service connection for hypertension and a skin condition. Regarding the skin condition, the Board ordered the Agency of Original Jurisdiction (AOJ) to obtain an opinion regarding whether the Veteran's lipomas were related to herbicide or jet fume exposure or whether they were caused by or aggravated by his service-connected PTSD and diabetes. The Board also ordered the AOJ to obtain an opinion regarding whether hypertension was either caused by or aggravated by his PTSD or diabetes. Pursuant to that remand, the Veteran received a VA examination in March 2018. The examiner opined that the Veteran's lipomas were not caused by service because the service treatment records were silent for a lipoma condition. The examiner then opined that the Veteran's lipomas were not related to herbicide or jet fume exposure because medical literature does not establish a causative relationship and the etiology of most lipomas is idiopathic, and also, they may appear on a hereditary basis. The examiner next opined the lipomas were not related to diabetes or PTSD because "medical literature review did not show that PTSD or [diabetes mellitus II] aggravate lipomas." Regarding hypertension, the examiner noted that service treatment records were silent for signs or symptoms of hypertension. The examiner then opined that hypertension was not due to diabetes because the Veteran was diagnosed with hypertension at the same time as diabetes and because the Veteran had normal renal function. The examiner finally opined that "PTSD has been associated with increased rates of cardiovascular risk factors such as obesity, dyslipidemia, tobacco use, and hypertension," but that a causal relationship between PTSD and hypertension has not been established. The Court found that remand was warranted because the March 2018 VA examination does not comply with the Board's prior remand order. It was noted that the Board's November 2017 remand ordered the VA examiner to provide opinions regarding whether the Veteran's disabilities were caused by or aggravated by his service-connected diabetes or PTSD. It was concluded that the March 2018 VA examiner did not provide an explanation for the opinion that the Veteran's hypertension was not caused by his diabetes, and the examiner did not provide an opinion as to whether the hypertension was aggravated by his diabetes. Further, despite noting that PTSD was associated with increased rates of hypertension, the examiner did not provide any explanation as to why he opined that PTSD did not aggravate his hypertension. In addition, the Court found that while the Board requested an opinion regarding whether the Veteran's skin condition was related to Agent Orange exposure or service-connected PTSD, the March 2018 VA examiner did not provide any rationale for the opinion that the Veteran's diabetes or PTSD did not cause his lipomas. The Court stated that the VA examiner's rationale regarding aggravation is conclusory, and the examiner failed to address the Veteran's report that his doctor opined that his lipomas were related to his diabetes. See January 2017 Board hearing. The Board's October 2020 remand directed the AOJ to schedule the Veteran for new VA examinations and corresponding etiological opinions correcting the inadequacies described in the JMPR. Unfortunately, in December 2020, the Veteran cancelled his pending examinations. It was noted that he was uncomfortable attending the examinations and requested that VA contact him at a later date. It is not clear to the Board why the Veteran did not wish to attend the examinations or if good cause has been shown that would warrant rescheduling the requested examinations. Given the limitations imposed on some by the Covid-19 pandemic, it is possible this was a contributing factor. Considering the above, particularly the fact that the Court has found that the previous etiological opinions are at least partially inadequate for rating purposes and that the Veteran has expressed a reluctancy to attend the examinations at the time previously scheduled, the Board finds that addendum opinions are warranted in this instance. The Board notes that the examiner has the discretion to determine whether further examination is necessary in order to render the requested medical opinion. It is emphasized that the duty to assist is not a one-way street, and the Veteran's reluctancy to attend any requested examinations may result in the denial of his claim. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from the March 2018 VA examiner (or a similarly situated examiner) in order to determine the nature and etiology of the Veteran's hypertension and skin disorder, both claimed to include as secondary to service-connected diabetes mellitus and PTSD. The examiner(s) is/are to be provided access to the Veteran's electronic claims file. The relevant examiner is requested to review all pertinent records associated with the claims file, the Veteran's service treatment records, post-service medical records, and lay statements of record. Any indicated diagnostic tests and studies should also be accomplished. It should be noted that the Veteran is competent to attest to factual matters of which he had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner(s) should provide a fully reasoned explanation. Following a review of the full record, the appropriate examiner should respond to the following: (a) The VA examiner must opine whether it is at least as likely as not (50 percent or higher degree of probability), that the Veteran's claimed hypertension and/or skin condition manifested in-service or is otherwise causally or etiologically related to his military service, to include herbicide exposure. (b) If not directly related to service, please offer an opinion as to whether it is at least as likely as not (50 percent or higher degree of probability) that the identified hypertension and/or skin disorder was caused by his service-connected diabetes mellitus and/or PTSD. With regard to the skin disorder, it is also requested that an opinion as to any relationship to jet fumes be set out. That is, could jet fumes cause or aggravate the skin disorder? (c) The examiner should then opine whether the hypertension and/or skin disorder is aggravated (i.e., permanently worsened beyond the normal progression of that disease) by his service-connected diabetes mellitus and/or PTSD. In offering any opinion, the examiner must consider the full record, to include the lay statements in support of the Veteran's claim. The examiner should also reconcile any prior report, if necessary. The rationale for any opinions offered should be provided. If the VA examiner determines that further examination is necessary in order to render the requested medical opinion, then the Veteran should be scheduled for such an examination. The Board reiterates that the duty to assist is not a one-way street, and the Veteran's failure to attend any requested examinations may result in the denial of his claim. 2. After the development requested has been completed, the AOJ should review any report to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the AOJ must implement corrective procedures at once. MICHAEL D. LYON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Miller, 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.