Citation Nr: 20057519 Decision Date: 08/31/20 Archive Date: 08/31/20 DOCKET NO. 14-19 164 DATE: August 31, 2020 REMAND Entitlement to service connection for hypertension is remanded. REMANDED ISSUE The Veteran served on active duty from March 1980 to June 1980, from February 1981 to November 1988 and from March 2003 to June 2003. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a December 2012 rating decision of the Jackson, Mississippi, Regional Office (RO) of the Department of Veterans Affairs (VA). Following an April 2017 hearing, in January 2018 and February 2019, the Board remanded the case. Entitlement to service connection for hypertension Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. “To establish a right to compensation for a present disability, a veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service”-the so-called “nexus” requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). A veteran is presumed to be in sound condition when s/he entered into military service, except for conditions noted on the entrance examination. 38 U.S.C. § 1111. If a preexisting disorder is noted upon entry into service, service connection may still be granted based on aggravation during service of that disorder. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b); see Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disorder during such service, unless there is a specific finding that the increase in disorder is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the pre-service disorder underwent an increase in severity during service. 38 C.F.R. § 3.306(b). The Veteran contends that her hypertension is due to her active duty service. At her April 2017 Board hearing, she reported feeling sick and experiencing headaches while in service. She stated that she had high blood pressure. Service treatment records (STRs) reflect a notation that the Veteran had hypertension and was on medication for the condition in December 2002. Post-service VA treatment records dated in October 2007 show a diagnosis of hypertension. An August 2011 VA treatment record reflects that the Veteran was taking medication, Lisinopril, for her hypertension condition. The Veteran was afforded a VA hypertension examination in November 2012. A diagnosis of hypertension was provided. The Veteran reported being diagnosed in 2007 and being prescribed medication at that time. She noted that during service, her blood pressure was elevated on two occasions, but was not given a diagnosis of hypertension or placed on medication. She indicated that she remained on medication, which she tolerated without difficulty. It was noted that she took Lisinopril. Blood pressure readings of 131/76, 147/86 and 139/82 were indicated. The VA examiner noted a review of the Veteran’s records which showed that she was not given a diagnosis of hypertension until 2007. A record dated in September 1987 was incorrectly tabbed to show a showed a diagnosis of vasovagal reaction versus hyperventilation. A December 2002 medical certificate shows that the Veteran was taking medication for high blood pressure. In the assessment of the remainder of her health history, no hypertension was identified, and no medication was noted. In a May 2018 VA medical opinion, the VA examiner opined that it was less likely as not that the Veteran’s hypertension had its onset during or caused by or otherwise related to active duty because the Veteran’s STRs were silent for a diagnosis of hypertension or sustained elevated blood pressure readings during the first and second periods of active duty and because she reported being treated for hypertension in 2002, prior to entry into third period of active duty in 2003. The medical knowledge to determine the natural progression of hypertension in an individual did not exist. The VA examiner also stated that during the third active period of active duty, the Veteran’s blood pressure stayed under control. Therefore, it is less likely as not that hypertension was aggravated by active duty. Pursuant to the Board’s February 2019 decision and remand, the claim was remanded to obtain a VA medical opinion requesting that the VA examiner determine whether the Veteran’s hypertension clearly and unmistakably preexisted the Veteran’s third period of service. An October 2019 VA medical addendum report shows that the Veteran took Lisinopril for her condition and blood pressure readings of 111/71, 135/81, 138/75 were indicated. The VA examiner stated that it was less likely as not that there was a causal link between hypertension and the third period of service, because hypertension was diagnosed clearly and unmistakably prior to third period of service with hypertension and being on medication. This was documented as such in December 2002. The Veteran’s third period of active duty was in March 2003. Her separation physical after the second period of active and medical records until 1999 were silent for hypertension. The VA examiner stated that the medical knowledge to determine the precise natural progression of hypertension in an individual did not exist. As such, there was “no evidence to support hypertension being clearly and unmistakably aggravated by any event during and by, the third period of service.” Regardless, there was no evidence of uncontrolled hypertension during the third period of active service. Unfortunately, the VA examiner utilized an incorrect standard in determining the applicability of the presumption of soundness. The question of the second prong of that standard is whether hypertension was NOT clearly and unmistakably aggravated by the third period of service. The opinion regarding “no evidence to support hypertension being clearly and unmistakably aggravated by any event during and by, the third period of service” is not responsive to the Board’s prior remand. As such, correction is needed upon a further remand. This case is accordingly REMANDED for the following action: Forward the claims file to a VA medical professional to address the possibility of a causal link between hypertension and the third period of service (from March to June in 2003). The medical professional is first requested to ascertain whether hypertension clearly and unmistakably preexisted the third period of service. If so, the medical professional is requested to provide an opinion as to whether hypertension clearly and unmistakably was NOT aggravated during the third period of service. (The medical professional is reminded that the response to this question must be phrased in the exact terms presented in this remand.) If not, the medical professional is requested to provide an opinion as to whether hypertension is at least as likely as not (a 50 percent or greater probability) etiologically related to the third period of service. All opinions must be supported by a rationale. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A-L Evans, 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.