Citation Nr: 20005451 Decision Date: 01/22/20 Archive Date: 01/22/20 DOCKET NO. 19-17 873 DATE: January 22, 2020 REMANDED Entitlement to an initial compensable rating for service-connected hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from October 1966 to September 1989. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a May 2018 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board further notes that whereas the Veteran was formerly represented by a Veterans Service Organization, he unambiguously stated in his June 2019 VA Form 9 that he no longer wished to have a representative for this appeal. The Board accordingly maintain jurisdiction, with the assumption that the Veteran is proceeding pro se. Entitlement to an initial compensable rating for service-connected hypertension is remanded. The Veteran contends that a compensable rating is warranted due to the fact that his hypertension is controlled by prescription medication, and that he otherwise meets the requirements for a compensable evaluation. Under 38 C.F.R. § 4.104, a compensable rating for hypertension may be warranted with diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; when an individual with a history of diastolic pressure predominantly 100 or more requires continuous medication for control. See 38 C.F.R. § 4.104, Diagnostic Code 7101. The Veteran was afforded a VA examination in May 2018. At that time, the Veteran’s blood pressure was measured as 150 (systolic) over 80 (diastolic), 148 (systolic) over 80 (diastolic), and 146 (systolic) over 78 (diastolic). Further, the examiner noted that the Veteran took medication for his disability. Since that time, the Board observes that in June 2019, the Veteran’s blood pressure was measured as 160 (systolic) over 80 (diastolic), while in July 2019, his blood pressure was measured as 180 (systolic) over 111 (diastolic). As the above evidence indicates a possible worsening of the Veteran’s hypertension since his last VA examination, an additional examination should be afforded to gauge the current level of severity of his disability. Additionally, the Veteran alleges in his August 2018 Notice of Disagreement that while seeking emergency treatment in February 2018, his blood pressure was purportedly measured as 161 (systolic) over 93 (diastolic). While there are private medical records from February 2018 indicating that the Veteran sought treatment for chest pain, the record does not reflect that blood pressure readings were obtained. Thus, a remand is required to allow VA to obtain authorization and request these records. The matters are REMANDED for the following action: 1. Obtain complete VA treatment records from February 2015 to the present. 2. Ask the Veteran to submit, or authorize VA to obtain on his behalf, any records of private care for his hypertension, to specifically include all records of any recent hospitalizations due to hypertension. Take all appropriate steps to obtain any identified private records, including an emergency room record in February 2018 that may confirm a blood pressure reading of 161/93. 3. Arrange for the Veteran to undergo a VA hypertension examination to assess the severity of his hypertension. The claims folder and a copy of this remand must be made available to the examiner in conjunction with the opinion and/or examination. All necessary tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner should report in detail all pertinent symptomatology and findings associated with the Veteran’s hypertension. In particular, the examiner should indicate whether the Veteran has had a history of diastolic pressure predominantly 100 or more (and, if so, whether same requires continuous medication for control), or else whether the Veteran has had a history of systolic pressure predominantly 160 or more. (Continued on the next page)   4. Then, readjudicate the issue on appeal. If the benefit sought on appeal remains denied, in whole or in part, issue the Veteran and his representative a Supplemental Statement of the Case and allow them a reasonable opportunity to respond before returning the record to the Board for further review. Irvin Cannaday Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Michael B. Engle, 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.