Citation Nr: 20056833 Decision Date: 08/27/20 Archive Date: 08/27/20 DOCKET NO. 15-46 747 DATE: August 27, 2020 REMANDED Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from January 1981 to December 1985. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this matter in October 2018 for further development. Entitlement to service connection for hypertension is remanded. Although the Board regrets the additional delay, remand is warranted for compliance with prior remand directives. In the 2018 Board remand, the Board directed the examiner to consider the full record, including various in-service blood pressure readings that may indicate pre-hypertension and stage one hypertension. See “Prevention, Detection, Evaluation, and Treatment of High Blood Pressure,” National Institutes of Health, National Heart, Lung, and Blood Institute (2003) (classifying “prehypertension” as a systolic reading of 120 to 139 or a diastolic of 80-89; “stage one hypertension” as a systolic reading of 140 to 159 or a diastolic reading of 90 to 99). (In addition to those blood pressure readings specifically identified in the Board remand, the record contains additional in-service blood pressure readings that may indicate pre-hypertension or stage-one hypertension. For example, in November 1984, the Veteran’s blood pressure was recorded as 122/76. April 1986 STR, p. 19. In March 1985, his blood pressure was recorded as 130/90. Id. at 13. In May 1985, his blood pressure was recorded as 128/90. Id. at 15. In September 1985, his blood pressure was recorded as 140/80. Id. at 7. On December 6, 1985, his blood pressure was recorded as 154/86. Id. at 29.) The October 2018 remand also specifically directed the examiner not to base the opinion on a lack of evidence of an in-service hypertension diagnosis. Despite these instructions, the June 2020 examiner made the conclusory determination that there was no nexus because the Veteran’s blood pressure “was intermittently elevated only without a diagnosis of hypertension.” Once VA undertakes the effort to provide an examination or opinion when developing a claim for service connection, an adequate examination or opinion must be provided. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the June 2020 opinion is inadequate for adjudication purposes. First, the examiner’s rationale did not comply with the October 2018 remand directives as the examiner was directed to not base the opinion on a lack of in-service diagnosis of hypertension. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand confers on the claimant, as a matter of law, the right to compliance with the remand order). Second, the examiner failed to provide a clearly stated rationale for the opinion as it is completely unclear why the Veteran’s current condition is unrelated to the plethora of pre-hypertensive and hypertensive blood pressure readings in service; in other words, the examiner did not explain whether the elevated readings could indicate an onset of hypertension. Remand is thus required for an adequate examination. Additionally, evidence indicates that relevant Social Security Administration (SSA) records may exist that are not currently associated with the Veteran’s claims file. In a July 2017 examination report, Dr. R.W. stated that the Veteran has a pending claim with SSA for disability benefits. See August 24, 2017 Correspondence, p. 12. The SSA records are not of record, may be relevant to the issue, and should be associated with the claims file. 38 C.F.R. § 3.159(c)(2). The matters are REMANDED for the following action: 1. Contact SSA to request and obtain the Veteran’s complete Social Security records, including all decisions and any medical records relied upon in making those decisions. 2. After completing action (1), schedule a VA examination to determine whether the Veteran’s hypertension is related to his military service. The entire claims file must be made available to the examiner and the examination report should include discussion of the Veteran’s in-service and post-service health history and assertions. All appropriate tests and studies should be accomplished and all clinical findings should be reported in detail. Following a review of the record, to include the Veteran’s lay statements, the examiner should answer the following question: Is it at least likely as not (50 percent or greater probability) that the Veteran’s currently diagnosed hypertension had its onset during military service TO INCLUDE PREHYPERTENSION, OR IS OTHERWISE RELATED TO THE ELEVATED BLOOD PRESSURE READINGS IN SERVICE? The examiner is advised that the lack of a diagnosis of hypertension in service is not definitive of the matter. The examiner must specifically address the following evidence in-service evidence indicating elevated, and potentially hypertensive or pre-hypertensive blood pressure readings: November 1984 blood pressure of 122/76; March 1985 blood pressure of 130/90; May 1985 blood pressure of 128/90; September 1985 blood pressure of 140/80; December 2, 1985, blood pressure of 138/90; December 3, 1985, blood pressure 132/88 and 126/88; December 4, 1985, his blood pressure of 132/90 and 132/88; December 5, 1985, blood pressure 120/80 and 130/80; December 6, 1985, 140/102, 154/86, 144/82; and the specific notation of “increased BP” in the notes section of the December 1985 Report of Medical History. The examiner must reflection consideration of the full record, to include the Veteran’s lay statements regarding in-service incurrence and continuity of symptomatology. If the examiner chooses to reject his reports, the examiner must provide a reason for doing so, and his lay statements must not be rejected due solely to an absence of contemporaneous or corroborating medical evidence, although this may be considered together with the other evidence of record. A clearly stated rationale for any opinion offered should be provided and must not be based on the lack of evidence of a hypertension diagnosis in his service treatment records. A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Watkins, 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.