Citation Nr: 22018295 Decision Date: 03/28/22 Archive Date: 03/28/22 DOCKET NO. 16-34 736 DATE: March 28, 2022 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for erectile dysfunction is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1967 to May 1970. These matters come to the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). These matters were before the Board and remanded in June 2020 and September 2021 for additional development. Although the Board regrets the additional delay, a remand is necessary to address a reasonably raised theory of entitlement and to obtain adequate medical opinions. 1. Entitlement to service connection for hypertension is remanded. The Board is unable to make a fully informed decision on the issue of service connection for hypertension. The Veteran contends that hypertension is due to his service-connected posttraumatic stress disorder (PTSD) with cannabis dependence and alcohol abuse. The Board finds that the medical and lay evidence of record reasonably raises the theory of entitlement of obesity as an intermediate step between service-connected disabilities and hypertension. In rendering a negative etiological opinion for hypertension as secondary to PTSD, a VA examiner noted the current Eighth Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8), published by the National Institute of Health, identified obesity as an increasingly prevalent risk factor for the development of hypertension. He further found that consistent with this etiology, the Veteran is classified as medically obese and weight loss has been specifically recommended as part of the treatment plan. November 28, 2021,VA Examination. VA mental health treatment records demonstrate that when Quetiapine was prescribed for treatment of PTSD in November 2006, the clinician informed the Veteran of the possible side effects, including weight gain and metabolic syndrome. By April 2009, VA mental health treatment records reflect that the Veteran was quite concerned with his weight gain that he attributed to Quetiapine. In September 2013, after Quetiapine had been discontinued, the Veteran noted that he gained some 40 pounds while taking the medication and was now losing weight slowly. In addition, the Veteran is service connected for coronary artery disease. During the Veteran's December 2014 heart disease VA examination, the Veteran described experiencing consistent fatigue with exertion since his diagnosis. The examiner opined that the Veteran has limitations with prolonged strenuous activities due to his heart condition. The Board is required to address all issues reasonably raised by either the claimant or the evidence of record. Robinson v. Peake, 21 Vet. App. 545, 552-56 (2008), aff'd sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009). As such, a remand is warranted to obtain a medical opinion that addresses the theory of entitlement reasonably raised by the evidence of record of obesity as an intermediate step between service-connected disabilities and hypertension. 2. Entitlement to service connection for erectile dysfunction is remanded. The Board is unable to make a fully informed decision on the issue of entitlement to service connection for erectile dysfunction. New medical opinions were obtained in October 2021. The examiner rendered negative opinions for direct service connection and service connection as secondary to PTSD and hypertension. In each negative opinion, the examiner opined that erectile dysfunction was most likely due to benign prostatic hyperplasia and advanced aging. With respect to direct service connection, the examiner reasoned that because erectile dysfunction was diagnosed 36 years after service, it more likely due to advanced aging and BPH and less likely than not related to active service. With respect to PTSD, the examiner pointed to August 2014 VA treatment notes demonstrating that PTSD was doing well without medications. The Board finds that the October 2021 VA medical opinions regarding direct service connection and as secondary to PTSD are inadequate. The examiner did not consider the lay statements of the Veteran regarding the onset of erectile dysfunction in rendering his opinions. During a December 2014 examination, the Veteran reported a long history of erectile dysfunction dating as far back as 1971, describing intermittent episodes of erectile dysfunction that became continuous in the 1980s. At that time, the Veteran indicated he had not had a relationship or been sexually active since that time. The examiner also did not consider the Veteran's historical use of medications prescribed to treat PTSD prior to August 2014 in rendering his opinions regarding secondary service as due to PTSD. As such, remand for an addendum opinion is warranted. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (a medical opinion is inadequate if it does not take into account the Veteran's reports of symptoms and history); Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006) (finding the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (medical opinions based on an incomplete or inaccurate factual premise are not probative). Finally, the Board finds that an opinion regarding secondary service connection as due to coronary artery disease is warranted. As hypertension is a risk factor or early symptom long preceding the development of cardiovascular diseases, the Board finds that these diseases are so closely related that this theory of service connection is reasonably raised. See August 18, 2020, VA Examination ; see also 38 C.F.R. § 3.309(a) (identifying the diseases encompassed under chronic cardiovascular diseases). As such, a remand is warranted to obtain a medical opinion that addresses the theory of entitlement reasonably raised by the evidence of record of service connection as due to coronary artery disease. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from the appropriate clinician to determine the nature and etiology of hypertension. The necessity of an in-person examination is left to the discretion of the examiner. The examiner should review the claims file and address the following: Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's service-connected PTSD with cannabis dependence and alcohol abuse and coronary artery disease, including associated symptoms and effects of the treatment thereof, caused or aggravated (i.e., worsened beyond the normal progression) the Veteran's obesity. If so, whether it is at least as likely as not (50 percent or greater probability) that the Veteran's obesity was a substantial factor in causing or aggravating non-service-connected hypertension. Whether it is at least as likely as not (50 percent or greater probability) that non-service-connected hypertension would not have occurred but for obesity caused by service-connected PTSD with cannabis dependence and alcohol abuse and coronary artery disease, including associated symptoms and effects of the treatment thereof. 2. Obtain an addendum opinion from the appropriate clinician to determine the nature and etiology of erectile dysfunction. The necessity of an in-person examination is left to the discretion of the examiner. The examiner should review the claims file and address the following. Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's erectile dysfunction was incurred in or is otherwise related to the Veteran's period of active service. The examiner must specifically acknowledge and consider the lay statements of the Veteran that noted intermitted erectile dysfunction as early as 1971 with continuous problems beginning in the 1980s. Whether it is at least as likely as not (50 percent or greater probability) that service-connected PTSD with cannabis dependence and alcohol abuse and coronary artery disease, including associated symptoms and effects of the treatment thereof, proximately caused or aggravated (i.e., worsened beyond the normal progression) the Veteran's erectile dysfunction. The examiner should address and consider the effects of past and present medications used to treat the Veteran's service-connected PTSD with cannabis dependence and alcohol abuse and coronary artery disease. 3. FOR ALL OPINIONS: A rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. The Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptoms and history, he or she must provide a reason for doing so. The examiner is reminded that the lack of medical evidence is not an adequate reason for discounting the Veteran's statements. K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Ball Jackson, 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.