Citation Nr: 21041114 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 16-11 423 DATE: July 8, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus and/or posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from April 1969 to November 1970, including service in the Republic of Vietnam. The Veteran is in receipt of the Bronze Star Medal. This matter is before the Board of Veterans' Appeals (Board) on appeal from an August 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In October 2018, the Veteran testified before the undersigned Veterans Law Judge at a video conference hearing. A transcript of the hearing is of record. The Board has previously remanded this matter three times, in May 2019, September 2020, and March 2021, for additional development. Unfortunately, as explained below, the Board is not satisfied that there was substantial compliance with its most recent remand. Therefore, the appeal must be remanded once again. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus and/or PTSD, is remanded. The Veteran seeks entitlement to service connection for hypertension, which he contends may be proximately due to or caused by his service-connected diabetes mellitus and/or PTSD. At his October 2018 Board hearing, the Veteran testified that he believes he had high blood pressure during military service, especially while serving in Vietnam, due to the high levels of stress he experienced. In its September 2020 remand, the Board found that the Veteran's testimony had raised the theory of entitlement to secondary service connection on the basis of service-connected PTSD. As such, the Board directed the RO to obtain a VA medical opinion to address whether the Veteran's hypertension may be caused or aggravated by his service-connected PTSD. The Veteran underwent a VA hypertension examination in October 2020. The Veteran's blood pressure at the time of examination was slightly high, with readings of 150/80, 156/78, and 139/75. Upon examination, the VA examiner opined that the Veteran's hypertension is less likely than not proximately due to or caused by PTSD. In making this finding, the examiner observed that the Veteran was not diagnosed with hypertension until 39 years after discharge and noted that current medical literature does not support a causal relationship between PTSD and hypertension. With regard to aggravation, the VA examiner noted that the Veteran has been prescribed quetiapine to treat his mental health condition, which is known to cause elevated blood pressure. However, the examiner noted that the medication was initiated approximately 10 years after his hypertension diagnosis with no evidence of aggravation of his hypertension after 12 months of treatment with the medication. In this regard, the examiner found that the Veteran had normal blood pressure readings both before and after he initiated quetiapine, noting that his blood pressure in December 2018, prior to initiating quetiapine, was 146/73, and after starting quetiapine, his blood pressure was 138/62 (in June 2019), 132/68 (in August 2019), and 138/70 (in February 2020). Therefore, the examiner opined that the Veteran's hypertension is less likely than not aggravated beyond its natural progression by service-connected PTSD, including the medication he takes to treat PTSD. In its most recent March 2021 remand, the Board found the October 2020 VA medical opinion to be inadequate. First, the opinion with regard to causation was not supported by sufficient medical rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two). Moreover, the examiner did not consider or address the Veteran's lay contention that he may have developed hypertension as a result of the high levels of stress he experienced due to his PTSD, as requested in the Board's examination directives. See Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007). Next, with regard to aggravation, the examiner only considered the impact of the medication the Veteran's takes to treat his PTSD; however, he did not consider whether any of the Veteran's reported symptoms of PTSD, such as anxiety or chronic sleep impairment, aggravate, or increase in severity, the Veteran's hypertension. Moreover, in finding that the prescription medication quetiapine did not cause an elevation in the Veteran's blood pressure, the examiner relied on an incomplete or inaccurate review of the Veteran's claims file when he concluded that the Veteran has had normal blood pressure readings. In fact, the Veteran's VA treatment records clearly document that the Veteran continues to have frequent high blood pressure readings: in May 2020, it was 171/73; in July 2020, it was 158/83, and in October 2020, it was 168/83. Notably, the three blood pressure readings at the time of the October 2020 VA hypertension examination were all elevated. In June 2020, a VA physician noted that the Veteran's blood pressure has been "poorly controlled." Given the above, the Board determined that the VA examiner omitted pertinent medical evidence when he based his conclusion that the medication quetiapine has not aggravated the Veteran's hypertension on a finding of three normal blood pressure readings in the Veteran's VA treatment records. See Reonal v. Brown, 5 Vet. App. 458, 460 (1993) (medical opinions based on an incomplete or inaccurate factual premise are not probative). Accordingly, in the March 2021 remand, the Board directed the RO to obtain an addendum VA medical opinion to address the above concerns. In April 2021, an addendum medical opinion was obtained from the same VA examiner who provided the inadequate October 2020 medical opinion. Review of the April 2021 opinion reveals that the examiner provided, nearly word-for-word, the same opinion as was provided in October 2020. The only additional information the examiner included in the new opinion was to state, without any supporting medical rationale, that the medical literature does not support a nexus between PTSD symptoms such as anxiety, suspiciousness, and chronic sleep impairment and the cause or aggravation of hypertension. The Board finds that the VA examiner did not provide a medical opinion that adequately responded to its remand directives. In light of the above, the Board notes that the record still does not contain a medical opinion that is sufficient to fairly decide the Veteran's service connection claim. Therefore, the claim must be remanded once again because the RO did not comply with the Board's prior remand directive to obtain an adequate medical opinion on the Veteran's behalf. See Stegall, 11 Vet. App. at 268. On remand, an addendum medical opinion must be obtained that is adequate for the Board to make an informed decision on the Veteran's claim. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007); Douglas v. Shinseki, 23 Vet. App. 19, 26 (2009). Accordingly, the matter is REMANDED for the following action: Forward the Veteran's claims file to a qualified VA physician (M.D.) WHO HAS NOT YET PROVIDED AN OPINION IN THIS CASE to provide an addendum medical opinion with regard to service connection for hypertension, to include as secondary to service-connected PTSD. A full VA examination need not be scheduled unless deemed necessary by the examiner or otherwise required by the evidence. The examiner must review the claims file in its entirety, to include a copy of this REMAND, and that review must be noted in the report. Thereafter, the examiner is asked to provide a fully-articulated medical opinion adequately addressing the following: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's hypertension was incurred in or caused by an in-service injury, illness, or event? (b) Is it at least as likely as not (50 percent or greater probability) that the Veteran's hypertension is caused by his service-connected PTSD, to include any medications taken to treat PTSD? (c) Is it at least as likely as not (50 percent or greater probability) that the Veteran's hypertension is aggravated by (increased in severity beyond its natural progression) his service-connected PTSD, to include any medications taken to treat PTSD? Please note, separate opinions must be provided for questions (b) and (c). In addressing the matter of aggravation, the examiner should note that it is not required that the claimed disability is shown to be aggravated beyond natural progression "predominantly" by PTSD, but rather, whether there is any contributing degree of aggravation beyond natural progression by the service-connected disability. Additionally, a recent Court of Appeals for Veterans Claims decision held that aggravation under 38 C.F.R. § 3.310(b) does not require that there be "permanent" worsening of the nonservice-connected disability. Any increase in disability is sufficient. Ward v. Wilkie, 31 Vet. App. 233, 239 (2019). The examiner is reminded that the term "at least as likely as not" does not mean "within the realm of possibility." Rather, it means that the weight of the medical evidence both for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against it. In providing the requested opinion(s), the examiner must specifically consider and address: (i) the Veteran's October 2018 Board hearing testimony in which he stated that he believes he had high blood pressure during military service, especially while serving in Vietnam, due to the high levels of stress he experienced; (ii) the impact of any reported symptoms of PTSD, to include anxiety, suspiciousness, and/or chronic sleep impairment; and (iii) the potential impact the medication quetiapine has on the Veteran's blood pressure in light of recent medical evidence that the Veteran's blood pressure continues to be "poorly controlled" (as of June 2020). It is imperative that the medical opinion reconcile all available evidence of record, to include the Veteran's lay statements and hearing testimony, service treatment records, post-service medical records, including all prior VA examinations and medical opinions, and any other pertinent evidence of record. The examiner is advised that the Veteran's lay contentions of record must be considered and weighed in making the determination as to whether a nexus exists between the claimed disability and military service. It should be noted that a lack of documented treatment for a claimed disability in service, while probative, cannot serve as the sole basis for a negative finding. The examiner must provide a complete rationale for any opinions offered, citing to the examiner's own expertise, medical principals, and/or evidence in the Veteran's record, when necessary, to support the conclusion reached. If an opinion cannot be reached without resorting to speculation, the examiner must fully explain why that is so. The Board reminds the examiner (AND THE AOJ) that failure to comply with the examination directives outlined herein will render the opinion inadequate and will result in further remand of the Veteran's claim. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Melissa Barbee, 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.