Citation Nr: 21040162 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 16-53 714 DATE: July 2, 2021 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for tremors is remanded. REASONS FOR REMAND The Veteran was a member of the Mississippi Air National Guard. He was activated for service with the United States Air Force from February 2002 to June 2002 and was deployed overseas during his period in support of Operation Enduring Freedom. He had combined National Guard service of 20 years, including verified active duty for training (ACDUTRA) from March 1983 to August 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2015 rating decision of the Department of Veterans' Affairs (VA) Regional Office (RO) in Jackson, Mississippi. This appeal was previously before the Board in July 2019. At that time, the appeal included the issues of entitlement to service connection for bilateral hearing loss, tinnitus, an acquired psychiatric disorder, and eczema. Based on the evidence of record, the appeal was remanded in its entirety for further development. Upon such development, the RO granted service connection for bilateral hearing loss, tinnitus, an acquired psychiatric disorder, and eczema. See Rating Decision dated September 2020. Accordingly, that decision represents a full grant of benefits sought and those issues are no longer in appellate posture. In regard to the remaining issues of entitlement to service connection for tremors and hypertension, the Board finds that another remand is required for additional evidentiary development. Records Development In the July 2019 remand, the Board noted that the objective evidence suggested that the Veteran's claimed conditions were related to his during a period of ACDUTRA or INACDUTRA. Upon remand, the RO was instructed to request the Veteran's service personnel records to confirm the ACDUTRA and INADUTRA dates of service, where possible. The Board notes that upon remand, the Board contacted NPRC to obtain the Veteran's National Guard Records; the negative responses indicate that no service treatment records were found. See PIES Response dated June 2, 2020. While the RO has found that the Veteran's service treatment records are unavailable, there has been no such finding regarding the Veteran's service personnel records. Thus, remand is required to either obtain the Veteran's personnel records or render a formal finding of unavailability. Similarly, in the July 2019 remand, the Board sought confirmation as to the Veteran's alleged duty location in the Southwest Asia theater of operations. Of record is a Defense Finance and Accounting Service (DFAS) payment worksheet which shows codes "50" and "22" on certain dates. However, there is no specification as to whether the Veteran was located in the Southwest Asia theater of operations on these dates. On remand, the RO should confirm whether the Veteran was stationed in the Southwest theater of operations. The RO should also seek verification from DFAS on the significance of "50" and "22" codes listed on days of each month. Hypertension In relation to his claim for hypertension, upon remand, the Veteran was afforded a VA examination in January 2020. Upon review of the record and examination of the Veteran, the examiner opined that the Veteran's hypertension was less likely than not incurred in or caused by service. In so finding, the examiner found that the Veteran's blood pressure was normal upon enlistment and over the course of his National Guard service. Unfortunately, the Board finds that remand is required to obtain an adequate nexus opinion. Here, the Board finds that the January 2020 negative nexus was based on an inaccurate factual premise. Specifically, while the examiner notes that the Veteran's blood pressure was normal throughout his service in the National Guard, the examiner failed to address the purported increase in both systolic and diastolic blood pressure during his time in the National Guard, nor did the examiner discuss the significance of the February 2002 Annual Medical Certificate, where the Veteran reported taking prescription medication for his blood pressure. In addition, although the January examiner found that stress was a risk factor, the examiner did not discuss whether the Veteran's hypertension was caused or aggravated beyond its normal progression by his service-connected PTSD. Accordingly, remand is required to obtain an adequate addendum opinion. Tremors Similarly, the Board finds that remand is required to obtain an adequate opinion regarding the Veteran's tremors, as the opinion and addendum of record are not sufficient to establish or disprove a nexus. Here, the January 2020 VA examiner found that essential tremors was a diagnosable chronic multi-symptom illness with partially explained etiology even though no exact cause has been noted. However, some factors include anxiety, Parkinson's and overactive thyroid. In the October 2020 addendum opinion, the examiner found that the Veteran's PTSD may cause temporary aggravation of essential tremors. In terms of rationale, the examiner was unable to determine a baseline level of severity of the Veteran's tremors. However, the examiner found that symptoms of PTSD, to include anxiety, would cause episodic aggravation, which is a temporary worsening without impact to the overall baseline. The Board finds this opinion regarding aggravation is inadequate and the Board cannot make a fully informed decision on the claim. See 38 U.S.C. § 5103A(d); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Here, the examiner was unable to determine the baseline severity level of the Veteran's tremors, but also found that the Veteran's PTSD did not impact the baseline severity of the Veteran's tremors. Given the internal inconsistency and speculation that serves as the basis of the negative nexus, the Board finds that remand is required to obtain another opinion. In providing the etiology opinion, the examiner should be aware of the facts that the Court recently held in Ward v. Wilkie, 31 Vet. App. 233 (2019), that a "permanent worsening" of a non-service-connected disability is not required to establish secondary service connection on the basis of aggravation (i.e., aggravation may include temporary worsening of a disability). The matters are REMANDED for the following action: 1. Obtain the Veteran's complete service personnel records, to include all documents pertaining to his service in the Mississippi Air National Guard. Verify all active duty for training and inactive duty for training dates. Contact the Defense Finance and Accounting Service (DFAS) to verify the codes "50" and "22" on the payment worksheet. If possible, use service personnel records to confirm the location of the Veteran's overseas service 2002 in a country specified as the Southwest Asia theater of operations, claimed to include Bahrain. Document all requests for information as well as all responses in the claims file. 2. Schedule the Veteran for an examination to determine the nature and etiology of his currently diagnosed hypertension. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease. The examiner should determine whether hypertension at least as likely as not (1) began during active service; (2) manifested within 1 year of discharge from active service; or (3) was noted during active service with continuity of the same symptomatology since service. The examiner should also determine whether it is at least as likely as not (50 percent or greater probability) the hypertension is aggravated by any service-connected disability to include PTSD. 3. Obtain a new medical opinion from an appropriate VA medical examiner to ascertain the etiology of the Veteran's tremors. The examiner is asked to review the Veteran's claims file prior to rendering the opinions requested below and must provide supporting rationale for all conclusions rendered. (a.) Provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) the Veteran's tremors are causally related to active service. (b.) Provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) the Veteran's tremors are caused or aggravated by any service-connected disability, to include PTSD. In providing answers to the above, the examiner should consider and discuss any lay assertions concerning the Veteran's essential tremors. The examiner should be aware of the facts that the Court held in Ward v. Wilkie, 31 Vet. App. 233 (2019), that a "permanent worsening" of a non-service-connected disability is not required to establish secondary service connection on the basis of aggravation (i.e., aggravation may include temporary worsening of a disability). The examiner must include in the medical report the rationale for any opinion expressed. 4. If service in Southwest Asia is confirmed through the service personnel records development requested above, schedule the Veteran for a VA examination to determine the nature and etiology of any undiagnosed illness or medically unexplained chronic multi-symptom illness manifested by tremor-related symptomatology. If the Veteran has any symptomatology that is not attributable to a known clinical diagnosis, the examiner should opine as to whether it is at least as likely as not that these symptoms are due to an undiagnosed illness or medically unexplained chronic multi-symptom illness resulting from service in Southwest Asia during the Gulf War. If so, the examiner should comment on the severity of such symptomatology and report signs and symptoms necessary for evaluating the illness under the rating criteria. The examiner is asked to respond to the following: (a.) Are there objective indications that the Veteran is suffering from chronic disability manifested by tremor conditions; the examiner must determine whether these symptoms can be attributed to any known clinical diagnosis or to a chronic multisymptom illness. For those symptoms and conditions that cannot be attributed to a known clinical diagnosis or chronic multi-symptom illness, the examiner must determine if there is affirmative evidence that the undiagnosed illness was not incurred during active service during the Persian Gulf War, or that the undiagnosed illness was caused by a supervening condition or event that occurred since the Veteran's departure from service during the Persian Gulf War. Joshua Castillo Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Orie, 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.