Citation Nr: 21000227 Decision Date: 01/04/21 Archive Date: 01/04/21 DOCKET NO. 16-12 412A DATE: January 4, 2021 REMANDED Entitlement to service connection for asthma is remanded. Entitlement to service connection for hypertension, to include secondary to coronary artery disease is remanded. Entitlement to service connection for diminished vision, to include secondary to hypertension is remanded. Entitlement to service connection for coronary artery disease, claimed as heart condition, to include secondary to hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from October 1972 to October 1973. In January 2020, the Board remanded the case for further development, which has been completed. Stegall v. West, 11 Vet. App. 268, 271 (1998). In August 2019, the Veteran and witness, J.J. testified at a Board hearing. The transcript is of record. 1. Entitlement to service connection for asthma VA has a duty to make reasonable efforts to assist Veterans in securing evidence necessary to substantiate their claim. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c) (2017). The record indicates that the Veteran may receive disability payments from the Social Security Administration (SSA). However, there are no Social Security applications, decisions, or medical records associated with an SSA claim in the record. As such, any records from Social Security should be obtained as they may contain evidence necessary for the Veteran to substantiate his claim. Murincsak v. Derwinski, 2 Vet. App. 363 (1992). Once VA undertakes the effort to provide an examination, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The January 2020 Board decision concluded that the Veteran was entitled to the presumption of soundness as the entrance examination from October 1971 did not indicate any symptoms or diagnoses of asthma. However, upon remand an opinion was obtained that only addressed whether asthma preexisted service. As the Board found that the Veteran’s lay statements are insufficient to rebut the presumption of soundness, a remand is necessary to obtain an opinion on direct service connection. 2. Entitlement to service connection for hypertension, to include secondary to coronary artery disease In February 2020 the VA examiner opined that it is less likely than not that hypertension incurred in or was caused by service as the Veteran’s service treatment records do not indicate that he was screened for elevated blood pressure and during an asthma attack it is not surprising to see elevated numbers. However, the examiner did note an elevated blood pressure of 142/110 with a normal pulse and respirations at 22 but concluded that it is more likely that hypertension become an issue later on due to other factors such as tobacco, alcohol and drug use and that it is more likely than not that his under treated or untreated respiratory conditions are responsible for hypertension. The Board finds this opinion inadequate. The examiner relied on the lack of screening for elevated blood pressure but failed to consider and discuss the Veteran’s lay statements that he received treatment for hypertension in service. See Fountain v. McDonald, 27 Vet. App. 258, 272-75 (2015) (indicating that a VA examiner may not generally rely on the absence of evidence as negative evidence). Furthermore, the Board finds that the examiner’s rationale lacks the degree of detail necessary for proper adjudication. The examiner concluded that hypertension is more likely than not due to respiratory conditions; thus, suggesting a possible link to in-service respiratory issues, but the examiner failed to provide further discussion. As such, the rationale lacks sufficient detail to allow the Board to make an informed decision. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). 3. Entitlement to service connection for diminished vision, to include secondary to hypertension The VA has a duty to assist, which includes providing a medical examination when necessary to make a decision on a claim. 38 C.F.R. § 3.159(c)(4)(i) (2017). The record contains sufficient evidence to trigger the VA’s duty to assist by providing a VA examination, as the Veteran has a current diagnosis of diminished vision and the service treatment records reveal a change in vision from 20/20 for distant vision in both eyes upon entry to active service to 20/40 distant vision for both eyes in August 1973, just prior to discharge. However, a VA examination to discuss the nature and etiology of the Veteran’s diminished vision has not been provided. Therefore, a VA examination for an opinion to determine the etiology of the Veteran’s diminished vision is warranted. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 4. Entitlement to service connection for heart condition, to include secondary to hypertension The Veteran's entitlement to service connection for heart condition, to include secondary to hypertension is inextricably intertwined with the entitlement to service connection for hypertension claim on appeal. Therefore, the Board finds that the claim for service connection for heart condition must be remanded as well. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (issues are inextricably intertwined when a decision on one issue would have a significant impact on another issue). The matters are REMANDED for the following action: 1. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. 2. 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). 3. Obtain from SSA all records pertaining to the Veteran's claim for disability benefits, if any, including copies of all medical records considered in deciding any claim. 4. After the above development is completed, 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 asthma is related to his active service or is caused by or aggravated by military service. The examiner is advised that there is insufficient evidence to establish that asthma preexisted service. 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. In all opinions rendered, the examiner is advised that the Veteran is competent to report his symptoms and treatment history. The examiner must specifically consider and discuss the Veteran’s contention of asthma since service that worsened thereafter. The opinion and rationale should reflect such consideration. If there is a medical basis to doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. The examiner should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 5. 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.) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s hypertension is related to 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 of the Veteran’s heart condition and/or asthma? (b.) If the answer to (a) is negative, is it at least as likely as not that the hypertension is aggravated (i.e., permanently or temporarily worsened) by the heart condition and/or asthma? (c.) 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. In all opinions rendered, the examiner is advised that the Veteran is competent to report his symptoms and treatment history. The examiner should consider the Veteran’s testimony that his hypertension began in service and was treated with Clonidine. If there is a medical basis to doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. The examiner should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 6. Schedule the Veteran for a VA examination with a medical professional with appropriate expertise. The examiner should review the Veteran’s claims file and comment on the following questions: (a.) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s diminished vision is related to active service or is caused by or aggravated by military service? The examiner should consider and discuss the vision findings at the entrance examination reporting 20/20 distant vision and the August 1973 examination revealing 20/40 distant vision and 20/50 near vision. See Service Treatment Records. (b.) Is it at least as likely as not (i.e., probability of 50 percent or higher) that diminished vision is proximately due to or the result of the Veteran’s hypertension, to include due to medications, such as Clonidine? (c.) If the answer to (b) is negative, is it at least as likely as not that the diminished vision is aggravated (i.e., permanently or temporarily worsened) by hypertension? (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 “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. In all opinions rendered, the examiner is advised that the Veteran is competent to report his symptoms and treatment history. If there is a medical basis to doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. The examiner should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 7. Upon completion of the above directives, complete any other necessary development after review of any additionally received records, to include an additional VA examination for heart conditions if warranted. 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.