Citation Nr: 21030324 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 12-19 674 DATE: May 18, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected post-traumatic stress disorder (PTSD), is remanded. Entitlement to service connection for headaches, to include as secondary to hypertension or service-connected PTSD, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 1978 to June 1981 and from March 1983 to May 1992, including service in Southwest Asia. The record indicates that he received various decorations, including the Bronze Star Medal, and served in combat. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2010 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). As an initial matter, the Board will summarize the procedural history of this appeal thus far. In December 2016, the Veteran testified before the undersigned at a hearing. A transcript of his testimony has been associated with the claims file. Thereafter, the Board remanded his claims for service connection for hypertension and headaches for additional development. Following this development, the matter returned to the Board in September 2018, at which time it issued a decision and denied his claims. Subsequently, the Veteran appealed this decision to the Court of Appeals for Veterans Claims (Court). During the pendency of that appeal, however, the parties entered into a Joint Motion for Partial Remand (JMPR) in August 2019. Pursuant to the terms of the JMPR, the parties agreed that the February 2018 VA examinations for headaches and hypertension were inadequate and that the Board had erred to the extent that it had relied upon these examinations in its decision. Additionally, the parties agreed that the Board failed to address whether 38 C.F.R. § 3.317, with respect to medically unexplained chronic multi-symptom illnesses, applied. As such, the Court vacated the portion of the September 2018 Board decision that denied service connection for hypertension and headaches. Thereafter, the matter returned to the Board. In November 2019, the Board remanded the claims for additional development in accordance with the JMPR. After further evidentiary development, the RO issued an October 2020 supplemental statement of the case that denied the claims once more. The matter now returns to the Board again. Service Connection Essentially, the Veteran contends that his hypertension and headaches are secondary to his service-connected PTSD. Additionally, he asserts that his headaches are secondary to his hypertension. Alternatively, he testified that he began suffering from hypertension and headaches in approximately 1990, when he was still in the military. Last, there is a contention that his headaches and hypertension are related to exposure to chemicals and other toxins in Southwest Asia during the Gulf War. The Veteran's service treatment records from his first period of service (i.e., June 1978 to June 1981) are unavailable. The Board finds that remand is warranted to obtain supplemental medical opinions on the etiology of his hypertension and headaches. To that end, the parties agreed in the JMPR that that opinions rendered in connection with the Veteran's February 2018 VA examination were inadequate. Although the Veteran submitted a private nexus opinion from Dr. M. in December 2016, this opinion was speculative. Accordingly, the Board previously directed the RO to obtain additional VA examinations with respect to the nature and etiology of his hypertension and headaches. The examiner was instructed to do the following: (1) opine as to whether it was at least as likely as not that his hypertension or headache disability had its onset during or was otherwise directly related to service, including exposure to environmental hazards in Southwest Asia; (2) opine as to whether it was at least as likely as not that his hypertension or headache disability was caused or aggravated by service-connected PTSD; (3) with respect to headaches, opine as to whether they were caused or aggravated by hypertension; and (4) opine as to whether his headaches or hypertension constituted an undiagnosed illness or a medical unexplained chronic multi-symptom illness (MUCMI). The examiners were asked to consider that service treatment records from June 1978 to June 1981 were not available, as well as Dr. M.'s private medical opinion. Subsequently, the RO arranged for the Veteran to undergo new VA examinations in December 2019. In the January 2020 VA medical opinions provided by the VA examiner, however, the December 2019 VA examiner opined that the Veteran had no chronic headache disability and that she could not confirm a diagnosis of hypertension. The Board finds these opinions inadequate, however, as the record is replete with evidence documenting current diagnoses of hypertension and complaints of tension headaches. See Reonal v. Brown, 5 Vet. App. 458 (1993). Although the record does not clearly indicate the reason for doing so, the RO arranged for the Veteran to undergo new VA examinations in August 2020. Afterwards, the August 2020 VA examiner provided medical opinions in September 2020. With respect to hypertension, the August 2020 VA examiner stated that the first finding of hypertension was in 2009 and that there was evidence of lifestyle and genetic factors that were risks for developing hypertension, including alcohol use. Ultimately, she opined that it was less likely than not that hypertension was directly related to his service, environmental hazards in Southwest Asia, or a MUCMI. She also opined that it was less likely than not that the Veteran's hypertension was secondary to his PTSD because no link has been established between PTSD and hypertension. With respect to headaches, the August 2020 VA examiner noted that the Veteran had reported headaches in 1985 after being diagnosed with Rocky Mountain spotted fever from a tick bite, but that his headaches had been acute and there was no evidence of chronicity of care. She ultimately opined that it was less likely than not that his headaches were related to hypertension or exposure to environmental agents while in Southwest Asia. There are several flaws with respect to the August 2020 VA examiner's opinions that render them inadequate. First, with respect to hypertension and headaches, her opinions are conclusory. For instance, although she opined that his headaches and hypertension were not related to environmental hazards in Southwest Asia, she did not explain why this was so. With respect to hypertension, she also failed to provide a fulsome explanation as to why it could not be related to his PTSD. Likewise, she did not sufficiently explain why the Veterans headaches could not be related to his hypertension. An opinion that lacks a rationale or that is conclusory is inadequate. Stefl v. Nicholson, 21 Vet. App. 120 (2007). Second, the August 2020 VA examiner failed to address all raised theories of entitlement. In her opinion on headaches, for instance, she failed to discuss whether headaches could have been secondary to PTSD. Moreover, the August 2020 VA examiner stated that one of the risks of developing hypertension was alcohol use without acknowledging that the Veteran was service connected for PTSD with alcohol abuse or discussing the possible relationship between the two. An adequate opinion must address all raised theories of entitlement. Id. Third, the August 2020 VA examiner's opinions are inadequate because she did not discuss all relevant evidence of record in providing her opinions. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). For example, she failed to discuss the Veteran's December 2016 Board hearing testimony regarding the onset of his headaches and hypertension. Moreover, she did not address Dr. M.'s private medical report that suggested that his hypertension was connected to his PTSD and that his headaches were related to his hypertension. Furthermore, she relied on an absence of contemporaneous treatment notes in the Veteran's service treatment records in forming her conclusions without accounting for his combat service or the pre-June 1981 service treatment records that are unavailable. Last, although the August 2020 offered opinions as to whether the Veteran's hypertension was "related" to his PTSD and whether his headaches were "related" to his hypertension, she did not separately address whether the conditions were aggravated by PTSD and hypertension, respectively. An adequate medical opinion on secondary service connection must separately address causation and aggravation. See El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (indicating that findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation under 38 C.F.R. § 3.310(b)). Recognizing that the August 2020 VA examiner's opinion contained various deficiencies, the RO requested clarifications in September 2020. The RO specifically noted that the August 2020 VA examiner had suggested in her opinion that the Veteran's PTSD with alcohol abuse might have been connected to his hypertension, and requested an addendum opinion as to whether hypertension was secondary to PTSD with alcohol abuse. Additionally, with respect to headaches, the RO indicated that the August 2020 VA examiner did not opine as to whether his headaches were secondary to his PTSD. In response to the RO's clarification request, a different VA examiner provided an addendum opinion in October 2020. In the October 2020 medical opinion, the VA examiner opined that the Veteran's hypertension was less likely as not caused or aggravated by service-connected PTSD because, for most adults, there is no identifiable cause of high blood pressure, but that it tends to develop gradually over many years. Citing an article from the Mayo Clinic on hypertension, the examiner stated that when hypertension develops secondary to an underlying condition, it tends to appear suddenly and cause higher blood pressure than primary hypertension. She listed various conditions that led to secondary hypertension, including sleep apnea, kidney problems, adrenal gland tumors, thyroid problems, certain congenital defects in blood vessels, certain medications, and illegal drugs. She concluded, however, that PTSD was not a medically recognized cause of hypertension per a literature review. She went on to explain that, given the physiology of hypertension, no "aggravation nexus" existed between PTSD and hypertension. Furthermore, she opined that hypertension did not constitute an undiagnosed illness or MUCMI because it had a clear and specific etiology and diagnosis. With respect to headaches, the October 2020 VA examiner opined that his headache disability was not caused by or aggravated by service-connected PTSD. She opined that the cause of tension headaches was unknown, but that experts believed it stemmed from heightened sensitivity to pain in people with tension headaches. She also stated that medical literature did not support hypertension as a cause of tension headaches and that no plausible secondary relationship had been established. Additionally, she stated that there was no evidence that his headaches had been aggravated by PTSD with alcohol abuse, because there was no evidence that alcohol abuse or depressive disorder caused tension headaches. Although she stated that stress was a "recognized trigger for tension headaches," a trigger "does not equate to causation." For similar reasons, she opined that the headache disability was less likely as not caused by or aggravated by hypertension. Last, she opined that the Veteran's headache disability did not constitute an undiagnosed illness or a MUCMI because tension headaches had a clear and specific diagnosis. Unfortunately, the October 2020 addendum opinion is also flawed in various respects. As with the August 2020 VA examiner's opinion, the October 2020 VA examiner failed to provide a sufficiently detailed rationale for her opinions. She also did not address various relevant evidence of record, such as the Veteran's lay statements or the private medical report from Dr. M. Additionally, she failed to separately address the issues of causation and aggravation with respect to secondary service connection. Although she nominally discussed both concepts, her discussion of "aggravation" focused on whether PTSD could cause hypertension or headaches, as opposed to whether it could worsen them. Moreover, the October 2020 VA examiner confusingly stated that stress could "trigger" tension headaches but also opined that his tension headaches were not caused or aggravated by PTSD. More confusingly, the October 2020 VA examiner stated initially that the causes of hypertension and tension headaches were unknown, but then stated that hypertension and tension headaches could not be MUCMIs because they both had clear diagnoses and etiology. In the interest of assembling clear and reliable findings, the Board finds that remand is thus warranted to obtain new VA medical opinions. Accordingly, the matters are REMANDED for the following action: 1. Obtain an addendum medical opinion from an appropriate VA clinician addressing the nature and etiology of his hypertension and headache disabilities. A complete explanation should be provided for all opinions rendered. After reviewing the claims file in its entirety, including a copy of this remand, the examiner is asked to render opinions on the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the hypertension or headache disability began during active service or are related to an in-service injury, event, or disease, including the Veteran's exposure to environmental agents while serving in the Southwest Asia theater of operations? The examiner is reminded that the Veteran served in combat. (b.) Is it at least as likely as not (50 percent or greater probability) that hypertension or the headache disability has been (1) caused by, or (2) aggravated (i.e., worsened beyond its natural progression) by the service-connected PTSD with depressive disorder and alcohol abuse? (c.) Is it at least as likely as not (50 percent or greater probability) that the headache disability has been (1) caused by, or (2) aggravated by the hypertension? (d.) Does the Veteran's hypertension or his headache disability constitute an "undiagnosed illness" or a "medically unexplained chronic multi-system illness"? A medically unexplained chronic multi-symptom illness is a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Signs or symptoms which may be manifestations of medically unexplained chronic multi-symptom illness include, but are not limited to fatigue, skin signs or symptoms, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, upper or lower respiratory systems signs or symptoms, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. In rendering the above opinions, the examiner is asked to consider the following: (a.) The Veteran's lay statements, including his December 2016 Board testimony. (b.) The Veteran's service treatment records for his period of service between June 1978 and June 1981 are unavailable for review. (Continued on the next page) (c.) The December 2016 private medical report from Dr. M. addressing the etiology of the disabilities. M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Rademacher, 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.