Citation Nr: 18145997 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 15-08 957A DATE: October 30, 2018 ORDER Entitlement to service connection for hypertension is granted. REMANDED Entitlement to arteriosclerotic heart disease is remanded. Entitlement to service connection for a heart disability other than arteriosclerotic heart disease, to include hypertensive vascular disease and valvular heart disease, is remanded. FINDING OF FACT The evidence is at least in equipoise that the Veteran’s service-connected diabetes mellitus type II aggravates his hypertension. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension have been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1961 to January 1963 and April 1963 to April 1966, with service in Vietnam. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision by the Department of Veterans Affairs (VA). The Board notes that the Veteran filed a claim specifically for arteriosclerotic heart disease and hypertensive heart disease, identifying the specific Diagnostic Codes associated with these disabilities. See March 2012 correspondence. The Agency of Original Jurisdiction (AOJ) adjudicated these issues separately during the appeal. Given the specificity to which the Veteran filed his claim, the Board will not merge these issues pursuant to Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), but instead has recharacterized his claim for hypertensive heart disease to encompass any heart disability other than arteriosclerotic heart disease. After the Veteran filed his substantive appeal (VA Form 9), his appeal of entitlement to service connection for depressive disorder, posttraumatic stress disorder (PTSD), and anxiety disorder was granted in a September 2018 rating decision (characterized as for PTSD). Because that decision represents a full grant of the benefit sought, those issues are not before the Board. Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Entitlement to service connection for hypertension. Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection requires evidence showing: (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a nexus between the current disability and the disease or injury incurred or aggravated in service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Establishing secondary service connection requires evidence of: (1) a current disability (for which secondary service connection is sought); (2) a service-connected disability; and (3) that the current disability was either caused or aggravated by the service-connected disability. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran is diagnosed with hypertension. See e.g., January 2007 VA hypertension examination. A January 2007 VA examiner opined that the Veteran’s hypertension is not caused by his service-connected diabetes mellitus type II or nephropathy, because his hypertension pre-dated such disabilities. However, the examiner also opined it was at least as likely as not that the Veteran’s diabetes aggravated his hypertension because there is evidence of microalbuminuria, which is an early sign of diabetic renal disease that can make pre-existing essential hypertension more difficult to control. See id. While the examiner appears to have provided a simultaneous contradictory opinion that the Veteran’s hypertension is not aggravated by his diabetes, see January 2007 VA diabetes examination, that opinion is given no probative weight because there is no rationale provided. Thus, the evidence is at least in equipoise, and service connection for hypertension due to aggravation by the Veteran’s service-connected diabetes mellitus type II is warranted. REASON FOR REMAND Entitlement to service connection for arteriosclerotic heart disease and a heart disability other than arteriosclerotic heart disease. The Veteran has been diagnosed with valvular heart disease and hypertensive heart disease. See January 2018 VA examination. A May 2018 examiner opined that it was less likely than not that the Veteran’s heart disability is related to his service-connected diabetes. See May 2018 VA opinion. This opinion is inadequate because it does not identify which heart disability is being discussed, relies on the absence of medical literature, and did not consider the Veteran’s hypertension, which is now service-connected. Additionally, the Veteran has stated that his heart disabilities may also be related to his exposure to herbicide agents in Vietnam, see September 2018 VA Form 646, Statement of Accredited Representative in Appealed Case, for which there is no opinion. As a result, remand for a new VA medical opinion is necessary. Because the Veteran’s heart disabilities are being reviewed by a VA examiner on remand, the issue of entitlement to service connection for arteriosclerotic heart disease should be remanded as well, as inextricably intertwined. The matters are REMANDED for the following action: 1. The AOJ should obtain copies of VA treatment records for the Veteran’s heart disabilities from August 2018 to the present. 2. After the above development is completed, the AOJ should arrange for a VA medical opinion by a cardiologist, if available, to determine the nature and likely cause of any heart disability, with examination only if deemed necessary by an examiner. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Please identify, by diagnosis, all heart disabilities present during the appeal period (from March 2012). (b.) For each heart disability diagnosed, is it at least as likely as not (50% or greater probability) that the disability was either caused or aggravated by the Veteran’s service-connected diabetes mellitus, nephropathy, or hypertension? Please explain why. The opinion must address whether the disability increased in severity beyond its natural progression (i.e., was aggravated). If aggravation is found, please identify to the extent possible the baseline level of disability prior to the aggravation. (c.) For each heart disability diagnosed, is it at least as likely as not (50% or greater probability) that the disability was either incurred in or otherwise related to the Veteran’s active duty service, specifically by exposure to herbicide agents in Vietnam? Please explain why. The examiner may not solely rely on an absence of a VA presumption for a diagnosed disability and must discuss the Veteran’s specific background. CONTINUED ON NEXT PAGE 3. If upon completion of the above action the issues remain denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Sandler, Associate Counsel