Citation Nr: 18153600
Decision Date: 11/28/18	Archive Date: 11/28/18

DOCKET NO. 15-22 558
DATE:	November 28, 2018
REMANDED
Entitlement to service connection for hypertensive heart disease is remanded.
Entitlement to a rating in excess of 10 percent for hypertension is remanded.
REASONS FOR REMAND
The Veteran had active service from May 1977 to November 1983.  
1. Entitlement to service connection for hypertensive heart disease is remanded.
The Veteran is service connected for hypertension and was afforded a VA examination in August 2013 for heart conditions.  The Veteran’s claim was originally stated as a request for service connection for enlarged heart.  However, VA must adjudicate any reasonable claim that derives from the Veteran’s request.  See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a disability claim includes any disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record).  Here, in the August 2013 VA examination, the examiner opined that the Veteran did not have an enlarged heart, thus any enlarged heart claim was less likely than not service connected.  However, the VA examiner also noted that the Veteran has cardiac hypertrophy and a METs level equivalent to 5 to 7.  The Board notes that hypertension is evaluated under Diagnostic Code 7101 for hypertensive vascular disease, and other cardiac conditions like hypertensive heart disease are evaluated under separate Diagnostic Codes based on symptoms such as cardiac hypertrophy.  38 C.F.R. § 4.104.  Here, the VA examiner did not elaborate on whether the Veteran has a separately diagnosable cardiac condition besides hypertension that could be evaluated as a separate disability or if such a disability would be related to active service or to the Veteran’s service-connected hypertension.  The RO should request an addendum opinion or a new VA examination if necessary to determine if there is a separately ratable cardiac disability.  
2. Entitlement to a rating in excess of 10 percent for hypertension is remanded.
The Veteran submitted a claim for increased rating for hypertension in January 2012.  The Veteran was afforded a VA examination in March 2012.  The Veteran’s recent VA treatment records since November 2015 are not part of the claims file and the RO should acquire them prior to the Board making a decision.   
The matters are REMANDED for the following action:
1. Obtain the Veteran’s VA treatment records for the period from November 2015 to the present.  
2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s cardiac conditions is at least as likely as not related to active service or proximately due to service-connected hypertension disability. The need for a new VA cardiac examination is left to the discretion of the examiner.  The examiner should respond to the following:
(a.) The Veteran’s August 2013 VA heart examination noted that he has cardiac hypertrophy and METs level of 5 to 7.  Do these symptoms result from a diagnosable cardiac condition other than hypertension? Do these symptoms result from the Veteran’s hypertension? 
(b.) If the Veteran has a diagnosed cardiac condition other than hypertension, is such a condition is at least as likely as not (50% probability or greater) related to or incurred during active service?
(c.) Is any diagnosed cardiac condition at least as likely as not (50% probability or greater) a result of or aggravated by the Veteran’s service-connected hypertension? 
 
DAVID L. WIGHT
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	E. Miller, Associate Counsel