Citation Nr: 21042766 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 17-02 637 DATE: July 13, 2021 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for headaches is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1974 to December 1978. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In April 2019, the Board remanded the issues on appeal for further development. There has not been substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In addition to the issues addressed herein, the Board also remanded the issue of a total disability rating based on individual unemployability (TDIU). During the pendency of the claim, while on remand, the RO granted TDIU for the entire period on appeal. As the May 2020 rating decision grants the Veteran TDIU effective August 30, 2012, this decision reflects an award of all benefits sought on appeal, and the appeal is considered satisfied in full. 38 U.S.C. § 7105(d); 38 C.F.R. §§ 20.101, 20.202. 1. Entitlement to service connection for hypertension is remanded. The Veteran asserts that his high blood pressure is directly related to his military service, including exposure to contaminated water at Camp Lejeune. The Veteran also asserts that his high blood pressure and nervous disorder, including anxiety, are intertwined. The Board acknowledges that in the April 2019 remand, it did not provide the RO with directives for the Veteran's hypertension claim regarding obtaining an opinion with rationale. In the Board's April 2019 remand, it was noted that evidence indicates the Veteran's hypertension may be associated with his anxiety, and "the Veteran asserts that his anxiety is part of the claimed neurobehavioral disorder, the Board finds that the claims are intertwined." In December 2019 the RO granted service connection for major depressive disorder with anxious distress claimed as neurobehavioral effects to include tense, trouble relaxing, short tempered and nervous system disease. The Veteran underwent a VA examination in February 2020 and the examiner noted a diagnosis of hypertension from 1991. However, the VA examiner also noted the Veteran's report of a diagnosis around 1979 and his report of first starting medication for hypertension in 1979. The VA examiner opined that the Veteran's hypertension was less likely than not proximately due to or the result of the Veteran's service-connected anxiety. The examiner's rationale acknowledged the Veteran's lay statements, including his reports of treatment. The examiner noted the Veteran's familial history of hypertension and indicated that this was a "nonmodifiable risk factor." The examiner also explained that the Veteran's example of an incident where his high blood pressure was impacted by his anxiety, was "incident based and not sustained." While the rationale is clear, the Board finds it incomplete because the VA examiner did not consider whether the Veteran's diagnosed hypertension could have been aggravated by his service-connected anxiety (major depressive disorder with anxious distress). El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). Additionally, although the examiner notes that the Veteran's service treatment records (STRs) do not contain treatment for hypertension, as claimed by the Veteran, there are readings of high blood pressure contained in those files. The Veteran's STRs show his blood pressure reading at the December 1978 separation examination as 130/78. He also had an October 1975 reading of 150/100 and an April 1976 reading of 100/90. Thus, an opinion regarding whether the Veteran's hypertension is directly related to service is also needed. Also, the Board notes that a November 2002 letter from the Veteran's private physician, Dr. J.M.L. appears to indicate that the Veteran's treatment of his anxiety via Xanax resulted in controlled blood pressure. However, aside from mentioning the letter, the VA examiner did not explain its significance, if any to the Veteran's claim. As a result, a remand is needed to obtain an addendum opinion that provides a complete rationale to support the opinion. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). 2. Entitlement to service connection for headaches is remanded. The Veteran asserts that his headaches are directly related to his military service, including exposure to contaminated water at Camp Lejeune. The Veteran reports that he had headaches in service but did not seek treatment for the same because he assumed it came with the job in service and he did not want to complain to a doctor about his pain. He also reports in his notice of disagreement that all of his problems, including headaches, began upon his discharge from service. The Veteran was afforded a VA examination in September 2019. The VA examiner indicated that the Veteran's correct diagnosis is migraine including migraine variants. The examiner opined that the Veteran's migraines were at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The examiner's rationale stated that his best diagnosis is migraine headaches. The examiner proceeded to explain why he diagnosed the Veteran with migraine headaches as opposed to tension headaches but did not explain why or how the Veteran's migraines were related to his military service. This opinion is inadequate because the examiner did not explain the nature and etiology of the Veteran's migraines and its relationship to his military service. In February 2020, another VA examiner opined that the Veteran's currently diagnosed headache disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner's rationale indicated that there was "no objective medical evidence for headache disorder in service" and "there is too large a gap till 2000's onset of documentation in c-file." The examiner concluded that the Veteran's mere mention of headaches in service were unrelated to trauma. The same VA examiner provided another unfavorable opinion in February 2020. The rationale was "during service, [the Veteran's headache] condition was acute only, with no plausible nexus given the gap of many years to onset of headache." The examiner indicated that there was no evidence of chronicity of care and a nexus was not established. In addition to the September 2019 VA examination report, the Board also finds both February 2020 VA opinions inadequate. Rather than explain why the Veteran's lay report of onset does not support the etiology, the examiner appears to dismiss the Veteran's competent lay reports. Furthermore, to the extent that the April 2021 opinion attempts to address chronicity or continuity of symptomatology, the significant consideration is not continuity or "chronicity of care" but rather symptoms. The Court has held, "[S]ymptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage v. Gober, 10 Vet. App. at 496 (1997). In other words, the examiner should have applied the Veteran's lay assertions of symptomatology rather than a lack of evidence of continuous treatment or care. Thus, an addendum opinion is needed. The matters are REMANDED for the following actions: 1. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's hypertension. a. The examiner should determine whether the Veteran's hypertension is at least as likely as not (50 percent probability or greater) related to service, to include exposure to contaminated water at Camp Lejeune. The examiner should review the in-service blood pressure readings and consider the Veteran's lay report of onset and treatment. b. The examiner is also asked to state whether it is at least as likely as not (50 percent probability or greater) that the Veteran's service-connected major depressive disorder with anxious distress aggravated his hypertension. The examiner is advised that aggravation under 38 C.F.R. § 3.310 (b) does not require that there be "permanent" worsening of the nonservice connected disability. The examiner is asked to address the November 2002 letter from Dr. J.M.L. regarding the implied relationship between the Veteran's use of Xanax and his controlled high blood pressure. A rationale must be provided for all opinions expressed. If any requested opinion cannot be provided without resorting to speculation, then the clinician must explain why this is so. 2. Obtain an addendum opinion from an appropriate clinician regarding the nature and etiology of the Veteran's headaches. a. The examiner must determine whether the Veteran's migraine headache is at least as likely as not (50 percent probability or greater) related to service, to include exposure to contaminated water at Camp Lejeune. If the examiner's opinion is unfavorable, the examiner is asked to explain the conflict between the current findings versus the September 2019 VA examination report. The examiner must consider the Veteran's August 2014 statement that he has had headache symptoms since his discharge from service. The examiner must also consider the Veteran's report that he had headaches during service but did not seek treatment for the same. The examiner is advised that the lack of contemporaneous records documenting complaints of or treatment for a headache condition, alone, is insufficient rationale for a medical nexus opinion. The examiner is reminded that the Veteran is competent to report symptoms of pain. (Continued on the next page) A rationale must be provided for all opinions expressed. If any requested opinion cannot be provided without resorting to speculation, then the clinician must explain why this is so. L. Chu Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Telamour, 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.