Citation Nr: 22018173 Decision Date: 03/28/22 Archive Date: 03/28/22 DOCKET NO. 16-17 570 DATE: March 28, 2022 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD) and/or exposure to herbicide agents, is remanded. REASONS FOR REMAND The Veteran served on active duty in the Air Force from July 1968 to July 1972. This matter before the Board of Veterans' Appeals (Board) is on appeal from a May 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania (Agency of Original Jurisdiction (AOJ)). This matter was previously before the Board in October 2018. At that time, the Board denied the Veteran's claim for entitlement to service connection for hypertension. The Veteran subsequently appealed the Board's decision to the Court of Appeals for Veterans' Claims (the Court). The parties filed a Joint Motion for Partial Remand (JMR) which the Court granted, vacating the Board's decision and remanding the claim due to the Board's failure to provide an adequate statement of reasons and bases for its decision. Thereafter, the Board remanded the claim again in September 2020 for additional development. The claim is now back before the Board for adjudication. The Veteran testified at a Travel Board hearing before a Veterans' Law Judge (VLJ) in August 2016. A transcript of the proceeding is of record. At the time the Veteran filed his claim for entitlement to service connection for hypertension in August 2011, he asserted that his condition was caused by his exposure to herbicide agents during his active duty service. His claim was denied in a May 2012 rating decision; while his private treatment records documented a diagnosis of hypertension, the AOJ held that there was no nexus linking his hypertension to his active duty service. Moreover, his condition did not manifest to a compensable degree within one year post-service. Thereafter, the Veteran filed a Notice of Disagreement; his appeal was subsequently perfected in April 2016. Prior to his appeal appearing before the Board for the first time, the Veteran presented testimony at a hearing before a Decision Review Officer (DRO) in November 2015 as well as at a hearing before a VLJ in August 2016. At the DRO hearing, the Veteran testified that he suspects he has had hypertension since he came home from Vietnam, but he did not consistently follow up with physicians post-service. During his August 2016 Travel Board hearing, however, he admitted his hypertension (and other issues he was claiming) did not manifest until "many years [after service]." He contended, however, that his exposure to herbicide agents namely Agent Orange caused his hypertension. Following the August 2016 hearing, the Board denied the Veteran's claim for entitlement to service connection for hypertension in an October 2018 decision. The Board determined that hypertension was not a disease entitled to presumptive service connection based on exposure to herbicide agents under 38 C.F.R. § 3.309(e), nor did it manifest to a compensable degree within any applicable presumptive period following his separation from the military. Similarly, the Board found there was no continuity of symptomatology or other medical evidence linking his hypertension to his military service. In April 2020, the Veteran appealed the Board's October 2018 decision to the Court. The parties agreed in a JMR that the Board failed to provide an adequate statement of reasons and bases for its determination that a VA examination or medical opinion was not required to assess the Veteran's hypertension. Notably, the Court found that the Board failed to address the Veteran's argument that his hypertension may be a symptom of his psychiatric disorder. On remand, the Board was instructed to provide adequate reasons or bases for its finding regarding whether a VA examination or opinion is necessary, to include whether the Veteran's hypertension is related to his acquired psychiatric disorder. The Court subsequently granted the parties' JMR. In a September 2020 decision, the Board remanded to obtain a VA examination and medical opinion that addresses the relationship, if any, between the Veteran's hypertension and his service-connected PTSD, to include any psychiatric medications. In December 2021, the Veteran received a VA examination for his hypertension. His diagnosis was confirmed, with the examiner noting a date of onset of 2004. The Veteran's current symptoms were documented as dizziness, and the examiner recorded that he is taking hydrochlorothiazide and Atenolol. He noted that the Veteran has to watch his activity levels due to the dizziness he experiences from his blood pressure. The nurse practitioner who performed the examination opined it is less likely than not that the Veteran's hypertension is proximately due to or the result of his service-connected PTSD, rationalizing as follows: "According to the CID, the risk factors for hypertension are: diabetes, unhealthy diet, physical inactivity, obesity, too much alcohol, tobacco use, [and] genetics and family history. I know of no credible medical authority or peer-reviewed study that has demonstrated PTSD and/or the medications used to treat it as likely proximate causes of hypertension. Veteran's claimed hypertension is less likely than not proximately due to his PTSD. By the same reasoning, there's no evidence to support that Veteran's claimed hypertension was aggravated beyond its natural progression by PTSD. Veteran's claimed hypertension was less likely than not aggravated beyond its natural progression by the Veteran's [PTSD]...and medication taken for this condition." The nurse practitioner stated he could not determine a baseline level of severity for the Veteran's hypertension, stating that the medical evidence is insufficient to support such a determination. Regardless, he reiterated the Veteran's hypertension is not at least as likely as not aggravated beyond its natural progression by his service-connected PTSD, to include his psychiatric medications, for the reasons listed in his rationale above. Shortly after the examination and opinion were associated with the file and a Supplemental Statement of the Case (SSOC) was issued, the Veteran's representative submitted a brief. The representative argued that the rationale provided by the VA examiner who performed the December 2021 examination was flawed. She purported that these is "enough epidemiologic evidence to conclude that there is a positive association between hypertension and exposure to herbicide agents," citing to the November 2018 National Academies of Sciences, Engineering, and Medicine finding that moved hypertension to the category of "sufficient" evidence of an association from its previous classification in the "limited or suggestive" category. Moreover, she posited that the examiner was incorrect in his statement that there are no credible medical authorities and peer-reviewed studies that demonstrate an association between PTSD and hypertension. She cited to a recent study of veterans published in the March 2018 journal Hypertension that found that experiencing a severe injury during war and then receiving a PTSD diagnosis at a later point doubled the risk of high blood pressure. She cited to additional research that came to similar conclusions. Other studies referenced in the brief suggest a correlation between anti-depressive medications and difficulties with blood pressure control. Once VA undertakes the effort to afford a veteran with an examination, VA must ensure that this examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical opinion is adequate when it is based upon consideration of the veteran's prior medical history and describes the disability in sufficient detail so that the Board's evaluation of the claimed disability will be fully informed. D'Aries v. Peake, 22 Vet. App. 97, 104 (2008). If an examination report is inadequate or fails to contain sufficient detail, the Board is required to return the report. See Bowling v. Principi, 15 Vet. App. 1, 12 (2001). In this case, the VA examiner's negative opinion was based on incomplete information; specifically, it did not consider medical treatises suggesting a correlation between hypertension and PTSD. Therefore, the VA examiner's opinions regarding the Veteran's claim for his hypertension is inadequate because it is based on an inaccurate factual premise. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based on an inaccurate factual premise has no probative value.); see also Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("if the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely.") (citing Reonal). On remand, the Board will seek a new opinion that considers the evidence cited by the Veteran's representative, suggesting a relationship between hypertension and PTSD. Moreover, while the Board recognizes that hypertension is not a condition warranting service connection on a presumptive basis pursuant to 38 C.F.R. § 3.309(e), the evidence and studies presented by the Veteran's representative should be considered to determine if the Veteran may be entitled to service connection on a direct basis as due to exposure to herbicide agents. The Board shall therefore remand for a new opinion. The matters are REMANDED for the following action: The AOJ should seek to obtain a medical opinion that considers the etiology of the Veteran's hypertension. The claims file must be made available to and be reviewed by the examiner. The examiner should specifically indicate whether it is a more nearly equal probability that the Veteran's hypertension occurred in or is otherwise etiologically related to the Veteran's military service, to include his exposure to herbicide agents. The examiner should also provide an opinion as to whether it is a more nearly equal probability that the Veteran's hypertension is proximately due to, caused by, or aggravated by the Veteran's service-connected PTSD. The examiner should consider the following: the Veteran's private treatment records, documenting a diagnosis of hypertension; the hearing testimony presented at the DRO hearing; the hearing testimony presented before the Board; the December 2021 VA examination; and the Veteran's brief associated with the file in February 2022, including the medical treatises and studies cited by the representative. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. A.M. CLARK Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Victoria A. Banis, 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.