Citation Nr: 21002018 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 13-29 537 DATE: January 12, 2021 REMANDED Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran honorably served on active duty from January 1970 to December 1971 to include service in the Republic of Vietnam. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). This matter was remanded in August 2017 and again in September 2019. The RO issued a Supplemental Statement of the Case (SSOC) in July 2020. This matter is now properly before the Board. The Veteran contends that his hypertension is caused by or aggravated by his previously service-connected disabilities. The Board remanded the issue of service-connection for hypertension in August 2017 and September 2019. In the most recent September 2019 remand the Board requested the examiner to consider whether the Veteran’s hypertension was incurred in or otherwise related to active service and whether the Veteran’s hypertension was caused or aggravated by his service-connected disabilities to include medications taken to treat his service-connected disabilities. The Veteran is currently service connected for Ischemic Heart Disease, Diabetes Mellitus and Pulmonary Hypertension associated with Ischemic Heart Disease. In April 2020, the Veteran attended a VA examination. The April 2020 examiner was provided with the Remand instructions. The examiner noted that the Veteran’s Ischemic Heart Disease, Diabetes Mellitus, and Pulmonary Hypertension and Lung Cancer were all diagnosed after the Veteran was diagnosed with hypertension. The examiner opined that it is less likely than not that these post-2002 diagnoses caused his original hypertension diagnosis because these diagnoses were made after 2002. The April 2020 examiner further directed in his opinion that the Veteran’s hypertension is not related to Agent Orange exposure, by referencing the November 2018 NAS assessment of hazardous material exposure that there was an “association” between hypertension and Agent Orange. The examiner concluded that because there is no direct proof that Agent Orange actually causes hypertension, that means that Agent Orange, like other hypertension-associated conditions, is less likely than not the primary cause of the Veteran’s hypertension. The examiner further opined that the Veteran’s hypertension was not proximately due to or the result of the Veteran’s service-connected condition. The examiner opined that because the Veteran’s hypertension was diagnosed before his diabetes was diagnosed, and because the Veteran has no renal insufficiency or microalbuminuria, it is less likely than not that the Veteran’s hypertension was proximately due to or the result of the Veteran’s service connected diabetes, including his diabetes medications. The April 2020 examiner did not provide an adequate opinion as to aggravation of the Veteran’s hypertension. The examiner opined that there is no medical journal article, medical study, or medical consensus that proves that insulin or the Veteran’s oral medications permanently aggravates hypertension. The examiner indicated that therefore, because the Veteran’s hypertension is better controlled now than when he was initially diagnosed with hypertension, and because the Veteran’s diabetes was diagnosed after he was diagnosed with hypertension, and because there is no evidence of diabetic-induced kidney disease, and because none of the Veteran’s anti-diabetic medications has been proven to worsen hypertension, it is less likely than not that the Veteran’s hypertension was aggravated beyond its natural progression by the Veteran's service-connected diabetes or his anti-diabetic medications. The Board finds that the examiner did not provide a complete rationale for the opinions provided. The examiner did not consider the etiology of hypertension and the connection between the Veteran’s other service-connected disabilities. The examiner focused solely on the aggravation as it relates to the Veteran’s diabetes. The examiner failed to provide an opinion as it relates to other medications the Veteran may be taking as it relates to his other service-connected disabilities aside from diabetes. Compliance with remand directives is not optional or discretionary, and the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). Therefore, remand is necessary to consider the Veteran’s medical history, family history and other risk factors. The matters are REMANDED for the following action: 1. Obtain a new medical opinion from an appropriate clinician on this Veteran’s claim for service connection of hypertension. If the examiner determines whether a physical examination is necessary to provide the requested opinions, such should be scheduled. The examiner must address the following questions: a. Is the Veteran’s hypertension at least as likely as not related to, or proximately due to or aggravated beyond its natural progression by service-connected Ischemic Heart Disease and/or the medications taken for this disability? Is the Veteran’s hypertension at least as likely as not related to, or proximately due to or aggravated beyond its natural progression by service-connected Diabetes Mellitus and/or the medications taken for this disability? Is the Veteran’s hypertension at least as likely as not related to, or proximately due to or aggravated beyond its natural progression by service-connected Pulmonary Hypertension associated with Ischemic Heart Disease and/or the medications taken for this disability. Is the Veteran’s hypertension at least as likely as not related to an in-service injury, event, or disease, including in service herbicide agent exposure? A complete rationale must be provided for all opinions. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should provide an explanation stating why this is so. TRACIE N. WESNER Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Hellina Y. Hailu, 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.