Citation Nr: 21040215 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 15-30 495 DATE: July 2, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1976 to November 1976; from March 1979 to March 1983; from November 2004 to January 2006; and, from December 2009 to February 2011. He had additional periods of service in the Army National Guard. This appeal comes before the Board of Veterans' Appeals (Board) from a March 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, denied service connection for hypertension. The Veteran's notice of disagreement (NOD) was received in May 2013. The RO issued the statement of the case (SOC) in July 2015, and the Veteran's VA Form 9, substantive appeal was received in August 2015. In February 2019 the Board remanded the case to the RO for further development and adjudicative action. Unfortunately. there has not been substantial compliance with the Board's February 2019 remand directives in connection with this claim, and additional development is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. The Veteran seeks service connection for hypertension, to include as secondary to PTSD. In February 2019, the Board remanded the claim to associate outstanding VA treatment records with the claims file; clarify the Veteran's duty status, specifically indicating whether he was on active duty, ACDUTRA, and INACDUTRA; and to obtain an additional addendum opinion addressing direct and secondary service connection. A VA addendum medical opinion was obtained in September 2019. The examiner opined that it was more likley than not that the Veteran's hypertension was incurred in the service, with no complications noted. The examiner reasoned that the Veteran had hypertension while in the service and that his first manifestation of having hypertension was seen on an examination dated August 14, 1998. The examiner also opined that it was less likely than not that the Veteran's hypertension was secondary to his PTSD. The examiner reasoned that hypertension is multifavorial and that "PTSD is not known in the literature to be a specific nexus for secondary hypertension." Another VA addendum medical opinion was obtained in November 2020, authored by the same examiner who provided the September 2019 opinion. The examiner opined that it was less likely than not that the Veteran's hypertension was aggravated beyond its normal progression by his service-connected combat PTSD. The examiner reasoned that while it is well known that combat PTSD, as well as all stress, causes a sympathetic response, there is no primary or secondary causative nexus between stress and hypertension. The examiner further stated that the literature in the claims file, noting that PTSD may put Veterans at risk for hypertension, is "not causative or creating a nexus." Additionally, the examiner stated that the Emory study notes that there is an increased risk but this does not create a primary or secondary nexus from conclusive epidemology. Finally, the examiner cited to new research from the Amercian Heart Association, which states that severe combat wounds and chronic PTSD may put service men and women at risk of having high blood pressure and that PTSD patients are known to have a higher risk for developing high blood pressure and cardiovascular disease. The Board finds that both addendum medical opinions, dated September 2019 and November 2020, are inadequate. More specifically, the September 2019 addendum is largely a reiterature of the September 2014 opinion of record. Further, the September 2019 addendum opinion lacks adequate rationale in support of the direct service opinion. Additionally, as to the secondary opinion, while the examiner acknowledged that hypertension is multifactoral, the examiner did not determine or acknowledge why PTSD could not be one of such causative factors. As noted above, the Board also finds that the November 2020 opinion is inadequate. Here, the examiner provided a negative nexus opinion but supported the opinion with speculative evidence that PTSD "may" increase the risk of developing hypertension. Further, the examiner did not adequately address whether the Veteran's hypertension was aggravated by his service-connected PTSD. As the opinions of record are inadequate, the Board finds that an additional remand is necessary to determine the nature and etiology of the Veteran's hypertension. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion by an appropriate clinician (and one who has never treated the Veteran) to determine the nature and etiology of his hypertension. If the examiner determines that an opinion cannot be provided without an examination, one should be scheduled. The Veteran's entire claims file, to include this Remand, must be made available to and reviewed by the examiner. Based on review of the record, the examiner is requested to provide the following opinions: (a) Provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that the Veteran's hypertension had its onset during a period of active duty or active duty for training (ACDUTRA). In doing so, please address the rationale provided by the September 2014 VA examiner, which noted the date of onset as August 14, 1998, as well as the conflicting opinions regarding the date of onset. (b) Provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that the Veteran's hypertension was caused by or aggravated by his service-connected PTSD. In doing so, please specifically address the medical literature cited by the Veteran's representative. See VBMS entry titled "Appellate Brief" on January 29, 2019. The examiner must also consider and address the Veteran's May 2013 lay statement wherein he contends that his hypertension worsened while on active duty in Afghanistan and notes that his high blood pressure medication was increased approximately six months after arriving in country. (c) If it is determined that there is another more likely etiology for hypertension, that should be stated. The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. The examiner should take into consideration that the Veteran is competent to report in-service and post-service symptom experiences and other witnesses are competent to report observable symptoms. If the examiner cannot provide an opinion without resorting to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. TIFFANY HANSON Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Modesto, Victor 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.