Citation Nr: 20056470 Decision Date: 08/26/20 Archive Date: 08/26/20 DOCKET NO. 16-53 527A DATE: August 26, 2020 REMANDED Entitlement to service connection for residuals of cerebrovascular accident, claimed as stroke is remanded Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from November 1969 and February 1972. The Board regrets the additional delay; however, a remand is necessary to ensure compliance with the Board’s prior remand instructions and to ensure that due process is met. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for residuals of cerebrovascular accident (CVA) and hypertension The November 2018 Board remand directed the examiner to provide opinions on the etiology of residuals of CVA and hypertension. The examiner was to opine on whether hypertension is related to active service or proximately due to his service-connected diabetes and whether residuals of CVA are related to active service or proximately due to his service-connected diabetes or hypertension. The examiner opined that hypertension is not due to military service because it was diagnosed after service and not due to diabetes because kidney function was normal at the time of diagnosis and it is not been aggravated beyond natural progression because diabetes is well controlled. The examiner also opined that the Veteran’s strokes are less likely due to or aggravated by diabetes as it is well controlled and concluded that his strokes are due to atrial fibrillation, which can be caused by hypertension. The Board finds these opinions to be inadequate for adjudication as the examiner failed to provide a rationale to support the above conclusions. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The matters are REMANDED for the following action: 1. Acquire updated VA and/or private treatment records. If such records are unavailable, the Veteran’s claim file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Obtain an addendum medical opinion from a medical professional with appropriate expertise. The examiner should review the Veteran’s claims file. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. Based on a review of the record, and a new examination if necessary, the examiner must address the following: (a.) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s residuals of CVA is related to his active service or is caused by or aggravated by military service. (b.) Is it at least as likely as not (i.e., probability of 50 percent or higher) that residuals of CVA is proximately due to or the result of hypertension and/or the Veteran’s service-connected diabetes? (c.) If the answer to (a) is negative, is it at least as likely as not that residuals of CVA is aggravated (i.e., permanently or temporarily worsened) by hypertension and/or the service-connected diabetes? (d.) If aggravation is found, the examiner should address the following medical issues: 1) the baseline manifestations of the disorder found prior to aggravation; and 2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected disorder. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. The term “aggravation” means a permanent increase in the claimed disability; that is, an irreversible worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. The examiner is advised that the Veteran is competent to report his symptoms and treatment history from in-service injury to the present. If there is a medical basis to support or doubt the history provided, the examiner should provide a fully reasoned explanation. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 3. Obtain an addendum medical opinion from a medical professional with appropriate expertise. The examiner should review the Veteran’s claims file. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. Based on a review of the record, and a new examination if necessary, the examiner must address the following: (a.) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s hypertension is related to his active service or is caused by or aggravated by military service. (b.) Is it at least as likely as not (i.e., probability of 50 percent or higher) that hypertension is proximately due to or the result the Veteran’s service-connected diabetes? (c.) If the answer to (a) is negative, is it at least as likely as not that hypertension is aggravated (i.e., permanently or temporarily worsened) by the service-connected diabetes? (d.) If aggravation is found, the examiner should address the following medical issues: 1) the baseline manifestations of the disorder found prior to aggravation; and 2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected disorder. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. The term “aggravation” means a permanent increase in the claimed disability; that is, an irreversible worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. The examiner is advised that the Veteran is competent to report his symptoms and treatment history from in-service injury to the present. If there is a medical basis to support or doubt the history provided, the examiner should provide a fully reasoned explanation. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 4. Finally, readjudicate the appeal. If the benefits sought on appeal remains denied, issue a supplemental statement of the case and return the case to the Board. G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. A. Prinsen 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.