Citation Nr: 21040802 Decision Date: 07/07/21 Archive Date: 07/07/21 DOCKET NO. 16-38 230 DATE: July 7, 2021 REMANDED Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1967 to June 1970. This appeal comes before the Board from a December 2015 Department of Veterans Affairs (VA), Regional Office (RO), rating decision. In November 2018, the case was remanded. The case has now been returned for appellate review. The Veteran had also initiated an appeal of the denial of service connection for a psychiatric disorder to include posttraumatic stress disorder (PTSD). Following the Board's November 2018 remand of this issue, an August 2020 rating decision granted service connection for PTSD. Because this award represented a total grant of benefits sought on appeal, this matter is not before the Board. Entitlement to service connection for hypertension. The Veteran contends that his current hypertension is related to his military service, to include as secondary to his service-connected PTSD. The Veteran's DD Form 214 verifies that he had active service in the Republic of Vietnam from January 1968 to January 1969, and therefore his exposure to herbicide agents including Agent Orange during such service is conceded. The National Academy of Sciences has concluded that there is sufficient evidence of an association between exposure to Agent Orange and hypertension, even though this condition is not on the list of diseases presumed to be related to herbicide agent exposure in 38 C.F.R. § 3.309(e). See Nat'l Acad. of Sci., Inst. of Med., Veterans & Agent Orange: Update 2018 (2018)). However, there is no medical opinion currently of record which addresses whether there is any relationship between the Veteran's current hypertension and his conceded in-service herbicide exposure. In addition, the Veteran submitted a treatise article in July 2016 which suggested a link between PTSD and cardiovascular disease. Following the Board's November 2018 remand, a VA psychologist opined in October 2019 that the Veteran's hypertension was at least as likely as not proximately due to or the result of his service-connected PTSD; however, the supportive rationale for this opinion was speculative in nature and not specific enough to this Veteran's case, as follows: "As a psychologist, I cannot definitively identify the nature and etiology [of] his hypertension, which is a medical condition, not a mental health disorder. However, research supports that many individuals with PTSD develop hypertension due to the increased anxiety and the [e]ffect on the nervous system. However, I cannot rule out other medical causes, as I am not a physician." Thereafter, in November 2019, a VA family medicine doctor opined that the Veteran's hypertension was less likely than not proximately due to or the result of his service-connected PTSD, with the rationale being that a review of current medical literature and research showed no physiological or biomechanical causal relationship between a mental health condition such as PTSD and the physiologic condition of hypertension, and that while anxiety states can cause a temporary elevation in blood pressure, they do not cause primary or secondary hypertension; however, this rationale did not address the treatise article provided by the Veteran (as was directed by the Board's November 2018 remand instructions), and no opinion was provided as to whether the Veteran's current hypertension may be aggravated by his service-connected PTSD. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). On remand, after all outstanding treatment records have been associated with the claims file (including from his private treatment providers at Stillwater Medical, as it was noted in a March 2021 VA treatment record that the Veteran continued to receive treatment from providers at that facility), a new examination with medical opinion should be obtained in order to adequately address the theories of service connection raised with regard to the Veteran's current hypertension. The matter is REMANDED for the following actions: 1. Ask the Veteran to complete a VA Form 21-4142 for all private providers who have treated him for his hypertension, including from Stillwater Medical. Make two requests for the authorized records from each identified provider, unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran's VA treatment records for the period from March 2021 to the present. 3. After all requested records have been associated with the claims file, schedule the Veteran for an examination by an appropriate clinician (or a telehealth interview if an in-person examination is not feasible) to determine the nature and etiology of his current hypertension. The electronic claims file must be made available to the examiner for review in conjunction with the examination. All necessary tests should be performed, and the results reported. The examiner must provide an opinion as to whether it is at least as likely as not that the Veteran's hypertension began during his active service (or within the first post-service year) or is otherwise related to any incident of his military service, to specifically include his conceded in-service exposure to herbicide agents during his verified service in the Republic of Vietnam. The examiner must also provide an opinion as to whether it is at least as likely as not that the Veteran's current hypertension is either caused by or aggravated by his service-connected PTSD, with specific consideration given to the treatise article submitted by the Veteran in July 2016 which suggested a link between PTSD and cardiovascular disease. The term "aggravation" means any incremental increase in disabilityany additional impairment of earning capacityin the non-service-connected condition resulting from the service-connected disability regardless of its permanence. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. (Continued on the next page) Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular clinician. C. CRAWFORD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. B. Yantz, Counsel The Board's decision in this case is binding only with respect to the instant matter(s) decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.