Citation Nr: 20023911 Decision Date: 04/07/20 Archive Date: 04/07/20 DOCKET NO. 15-27 114 DATE: April 7, 2020 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1974 to June 1978, which included service during the Vietnam Era. The Veteran passed away in February 2017. The Appellant is his surviving spouse and has been substituted in as the claimant. In September 2018, the Board remanded this matter for further development; namely, to obtain an addendum VA medical opinion. The Board finds that its prior directives were not substantially complied with and as will be discussed further an additional remand is necessary. A remand by the Board confers on the Veteran or other claimant, as a matter of law, the right to substantial, but not strict, compliance with the remand orders. See Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for hypertension, to include as secondary to service-connected disabilities, is remanded. Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Appellant’s claim so that she is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. In addition, where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall, 11 Vet. App. at 268. VA’s duty to assist includes a duty to provide a medical examination or obtain a medical opinion where it is deemed necessary to make a decision on the claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4); Duenas v. Principi, 18 Vet. App. 512 (2004); Robinette v. Brown, 8 Vet. App. 69 (1995); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In addition, once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). For below noted reasons, the Board finds that an addendum VA medical opinion is needed in order to determine the nature and etiology of the Veteran’s hypertension. In accordance with the Board’s remand noted above, addendum VA medical opinions were obtained in September 2019. The VA examiner proffered negative nexus opinions, finding it was less likely than not the Veteran’s hypertension was proximately due to or aggravated beyond its natural progression by his service-connected disabilities. With respect to the issue of causation, the VA examiner indicated none of his service-connected disabilities were risk factors for developing hypertension. However, the Board notes the VA examiner also acknowledged that stress was a risk factor for developing hypertension. In doing so, the VA examiner did not reconcile the contention that the stress from the Veteran’s service-connected disabilities caused his hypertension with their findings. Cf. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (2006). With respect to the issue of aggravation, the VA examiner simply found there was no objective evidence available showing his hypertension was aggravated beyond its natural progression without any supporting rationale after largely reiterating their findings addressing causation. Cf. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-04 (2008). In doing so, the VA examiner failed to address the numerous elevated blood pressure readings of record, which at times necessitated changes in the medication prescribed to control it. The Board notes that during a September 2014 VA examination, the Veteran reported the onset of symptoms related to his hypertension in-service. See September 2014 Hypertension VA Examination. However, the September 2014 VA examiner limited their negative nexus opinion to the issue of secondary service connection and the September 2019 VA examiner was not asked to proffer an opinion on the issue of direct service connection. A review of the Veteran’s service treatment records (STRs) reveals at least one elevated blood pressure reading during his active duty service in July 1976 and another a year and a half later in December 1979. See July 1976 Chronological Record of Medical Care (noted blood pressure reading of 120/90 millimeters of mercury (mm Hg)); December 1979 S.C.P.M.G. Clinic Progress Record (noting blood pressure reading of 122/90 mm Hg). Considering the above, a remand is necessary to obtain another addendum VA medical opinion. The matters are REMANDED for the following action: 1. Contact the Appellant to determine if there are any relevant, outstanding private treatment records. If so, undertake all appropriate development necessary to obtain the records from each private treatment provider and/or facility identified by her. 2. Once the first request has been completed, to the extent possible, obtain an addendum medical opinion from an appropriate medical professional regarding the nature and etiology of the Veteran’s hypertension. After reviewing the record, the examiner should: (a) Opine as to whether it is at least as likely as not (50 percent probability or greater) the Veteran’s hypertension was caused by or otherwise related to his active duty service and explain why. (b) If the Veteran’s hypertension was not caused by or otherwise related to his active duty service, opine as to whether it is at least as likely as not (50 percent probability or greater) proximately due to or aggravated beyond its natural progression by his service-connected disabilities, to include the medications prescribed therefor, and explain why. The examiner is reminded that an opinion must address both causation and aggravation. In rendering an opinion, the examiner should consider the relevant STRs, to include a July 1976 Chronological Record of Medical Care noting an elevated blood pressure reading of 120/90 mm Hg during the Veteran’s active duty service. In rendering an opinion, the examiner should consider the relevant medical evidence of record, to include a December 1979 S.C.P.M.G. Clinic Progress Record noting a blood pressure reading of 122/90 mm Hg a year and a half following separation from active duty service; a March 2013 VA Mental Health Note from Dr. C.S. opining the Veteran’s hypertension was more likely than not caused by his anxiety disorder; an August 2013 letter from Dr. B.S.C. opining his hypertension was more likely than not related to his anxiety; and generally, the post-separation medical evidence of record documenting elevated blood pressure readings and changes in the medication(s) prescribed therefor. In rendering an opinion, the examiner should consider the arguments raised and medical literature cited in an August 2018 Written Brief Presentation and March 2020 Written Brief Presentation from the Appellant’s representative. In rendering an opinion, the examiner should consider the relevant lay evidence of record, to include the Veteran’s lay statements prior to his passing, to include his statements during the September 2014 VA examination that the symptoms of his hypertension onset during service. (Continued on the next page)   3. After undertaking any additional development deemed appropriate and giving the Appellant a full opportunity to supplement the record, readjudicate the appeal in light of any additional evidence associated with the record. If any benefit sought on appeal remains denied, the Appellant and her representative should be furnished with a Supplemental Statement of the Case and afforded the applicable opportunity to respond before the record is returned to the Board for further review. Julie C. Unger Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Suh, 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.