Citation Nr: 21031150 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 07-38 080A DATE: May 20, 2021 THE ISSUE Entitlement to service connection for hypertension to include as secondary to service-connected post-traumatic stress disorder (PTSD), to include medication used for treatment of PTSD. REMANDED Entitlement to service connection for hypertension to include as secondary to service-connected post-traumatic stress disorder (PTSD), to include medication used for treatment of PTSD is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1975 to June 1982. This matter initially came to the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision that, in pertinent part, denied service connection for hypertension. The Veteran timely appealed. In March 2011, the Veteran testified during a hearing before the undersigned at the Regional Office (RO). During the hearing, the Veteran submitted additional evidence and waived initial consideration of the evidence by the RO. In June 2011 and in June 2012, the Board remanded the matter for additional development. In a January 2013 decision, the Board denied service connection for hypertension. The Veteran appealed the January 2013 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a July 2014 Memorandum Decision, the Court vacated the Board decision and remanded the case to the Board for readjudication. In the July 2014 Memorandum Decision, the Court explained that the question in this case depended on the resolution of the conflicting evidence in the record as to when the appellant's hypertension began. Thereafter, the case was returned to the Board. This matter was remanded by the Board in December 2014 and again in March 2017. The Board remanded the Veteran's appeal a second time in March 2017 because there continued to be conflicting evidence with regards to the date of onset of the Veteran's hypertension. Although the Veteran was afforded a VA examination and opinion in May 2015, the Board remanded this matter for an addendum opinion. The May 2015 VA examiner opined that the Veteran's "hypertension was diagnosed in 2003, prior to onset of medications taken for PTSD." However, the May 2015 VA examiner did not support his finding as to the onset of the Veteran's hypertension with specific evidence in the record. Moreover, the VA examiner did not address the Veteran's assertions as to contemporaneous and/or later onset of hypertension. As the Court held in Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994), a medical opinion that "fails to discuss all the evidence which appears to support appellant's position," and was accepted by the VA, contributed to inadequate reasons or bases. Therefore, this issue was remanded for a complete consideration of the evidence contained within the entirety of the claims file and for a complete rationale to support the examiner's opinion. In January 2020, the Board denied entitlement to service connection for hypertension. The Veteran appealed the January 2020 Board decision to the Court. In a January 2021 Joint Motion Remand (JMR), the Court vacated the January 2020 Board decision and remanded the matter back to the Board. Entitlement to service connection for hypertension to include as secondary to service-connected post-traumatic stress disorder (PTSD), to include medication used for treatment of PTSD is remanded. Upon review, the Board finds that an addendum opinion is needed to sufficiently address the issue raised by the Court in its July 2014 Memorandum Decision and January 2021 JMR. In the July 2014 Memorandum Decision, the Court explained that the question in this case depends on the resolution of the conflicting evidence in the record as to when the appellant's hypertension began. The Veteran asserts that the record contains evidence that his hypertension started in 2007, and that treatment with trazodone started before 2007. See June 2007 VA medical record; see October 2006 VA medical record. However, the August 2012 VA examiner found that the Veteran was diagnosed with and treated for hypertension before starting trazodone. The examiner found that the record notes the onset of the Veteran's hypertension at around 2003-2004, although the exact date of the diagnosis was not clear, and that the Veteran was treated with trazodone from 2007-2009. While the record contains evidence of a diagnosis of hypertension in 2007, the record also contains evidence that points to a "plausible basis" for a finding of inception around 2003-2004. See January 2010 private medical record; see also 2008 VA medical record ; see also November 2005 medical record. Therefore, as set-forth by the Court in its Decision Memorandum, in its March 2017 decision, the Board observed that the question in this matter depends on the resolution of the conflicting evidence in the record as to when the appellant's hypertension began. The Veteran was afforded a VA examination and opinion in May 2015. The May 2015 VA examiner opined that the Veteran's "hypertension was diagnosed in 2003, prior to onset of medications taken for PTSD." However, the May 2015 did not support his finding as to the onset of the Veteran's hypertension with specific evidence in the record. Moreover, the VA examiner did not address the Veteran's assertions as to contemporaneous and/or later onset of hypertension. As the Court held in Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994), a medical opinion that "fails to discuss all the evidence which appears to support appellant's position," and was accepted by the VA, contributed to inadequate reasons or bases. Therefore, this issue must be remanded for a complete consideration of the evidence contained within the entirety of the claims file and for a complete rationale to support the examiner's opinion. Based upon this finding, the Board remanded the matter in March 2017 in order to afford the Veteran a new VA opinion. Specifically, the March 2017 remand directives asked the examiner to opine whether any of the medicine the Veteran took for his service-connected PTSD aggravated his hypertension. Upon remand, the Veteran was afforded a new VA opinion in May 2019, in which the examiner opined that the Veteran's hypertension was not at least as likely as not "permanently aggravated" by his service-connected PTSD medication. However, as noted in the January 2021 JMR, the examiner did not address all the medications the Veteran was receiving for his service-connected PTSD. Specifically, the Court found that while the examiner addresses the Veteran's use of bupropion, the examiner did not address the Veteran's use of hydroxyzine, sertraline, prazosin, aripiprazole, or trazodone. Regarding aggravation, the January 2021 JMR found that the VA examinations of records did not use the appropriate standard when providing the opinion. Specifically, as directed by the previous Board remand directives in June 2011, June 2012, and March 2017, the examiners found that his PTSD did not cause permanent worsening of his hypertension. Per a recent decision from the Court, and as noted in the January 2021 JMR, "any incremental increase in disability and additional impairment of earning capacity in non-service-connected disabilities resulting from service-connected conditions regardless of its permanence" constitutes aggravation. Ward v. Wilkie, 31 Vet. App. 233 (2019). Accordingly, a remand is required to obtain an adequate opinion addressing whether the Veteran's service-connected diabetes has aggravated his hypertension. Finally, the January 2021 JMR found that the Board erred in its January 2020 decision denying entitlement to hypertension when it did not adequately address the findings of the October 2008 medical examiner who found "[i]t is as likely as not that the patient's post-traumatic stress disorder has caused transient elevations in blood pressure that would be considered aggravation but in my opinion it is not as likely as not that this caused permanent blood pressure changes for this patient." Thus, unfortunately, given the Court's vacatur and remand, the Board once again finds the medical evidence of record to be insufficient to make a decision on the claim and remands this matter for an addendum opinion. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records. Should they exist, associate such with the Veteran's electronic claims file. 2. Thereafter, return the claims file to the May 2019 VA examiner, or, if the examiner is unavailable, to another suitably qualified examiner, to provide an addendum VA medical opinion to address the etiology of any hypertension found to be present, and to identify the date of likely onset of hypertension. If it is determined that another examination is needed to provide the required opinions, the Veteran must be afforded the appropriate VA examination. The examiner must note that the claims file was reviewed. After a review of the claims file, the examiner must respond to the following: (a) The examiner should specifically identify the date of likely onset of the Veteran's hypertension. A complete explanation for the date identified, supported by facts contained within the record, is requested. The examiner is also directed to consider and address the Veteran's contentions as to a contemporaneous/ later onset (contemporaneous to the diagnosis and treatment of PTSD), and the evidence of record that the Veteran uses to support such contention. (As noted above). (b) The examiner should opine whether it is at least as likely as not (50 percent probability or more) that hypertension is related to active service. Please provide a complete explanation for the opinion. (c) The examiner should also opine whether it is at least as likely as not (50 percent probability or more) that the service-connected PTSD, and/or medications taken for treatment, caused hypertension. The examiner should specifically address all medications: bupropion, hydroxyzine, sertraline, prazosin, aripiprazole, and trazodone. Please provide a complete explanation for the opinion. (d) The examiner should also opine whether it is at least as likely as not (50 percent probability or more) that the service-connected PTSD, and/or medications taken for treatment, aggravated the Veteran's hypertension beyond the natural progress of the disease. The examiner should specifically address the following medications: bupropion, hydroxyzine, sertraline, prazosin, aripiprazole, and trazodone Please provide a complete explanation for the opinion. If aggravation is found, the examiner should address the following medical issues: (1) the baseline manifestations of the Veteran's hypertension found prior to aggravation; and (2) the increased manifestations which, in the examiner's opinion, are proximately due to a service-connected disability. The examiner must address the findings of the October 2008 examiner who found "[i]t is as likely as not that the patient's post-traumatic stress disorder has caused transient elevations in blood pressure that would be considered aggravation but in my opinion it is not as likely as not that this caused permanent blood pressure changes for this patient." If necessary, the examiner must reconcile his or her findings with that the October 2008 report. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. If the examiner determines that an opinion cannot be made without resort to mere speculation, then it should be clear in the examiner's remarks whether it cannot be determined from current medical knowledge that a specific in-service injury or disease can possibly cause the claimed disorder, or whether the actual cause is due to multiple potential causes. In other words, simply stating that an opinion cannot be made without resort to mere speculation is not acceptable without a detailed explanation as to why this is so. See Jones v. Shinseki, 23 Vet. App. 382 (2010). All opinions and conclusions expressed must be supported by a complete rationale in a report. Review of the entire file is required; however, attention is invited to the October 2008, January 2010, July 2011, and August 2012 medical opinions, and with the Veteran's credible testimony before the Board in March 2011. 3. After ensuring that the requested actions are completed, readjudicate the claim on appeal. If the benefits sought are not fully granted, furnish a supplemental statement of the case (SSOC) to the Veteran before the claims file is returned to the Board, if otherwise in order. Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. E. Geary, 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.