Citation Nr: 21002647 Decision Date: 01/14/21 Archive Date: 01/14/21 DOCKET NO. 15-37 985 DATE: January 14, 2021 ORDER Entitlement to service connection for hypertension, as secondary to coronary artery disease (CAD), is granted. FINDING OF FACT Hypertension is related to the Veteran’s service-connected CAD. CONCLUSION OF LAW he criteria for service connection for hypertension, as secondary to CAD, are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Navy from June 1968 to February 1970. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in October 2013 by the Department of Veterans Affairs (VA) Regional Office in Nashville, Tennessee. In September 2018, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In January 2019, the Board remanded the case for additional development. In August 2020, the Board remanded the case for an addendum opinion related to the issue above, and it now returns for further appellate review. Service connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303(a). 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. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. §§ 3.303(d). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995)(en banc). Entitlement to service connection for hypertension, as secondary to CAD The Veteran contends that his hypertension is secondary to his service-connected CAD. In September 2019, in response to the Board’s January 2019 remand, the Veteran underwent a VA examination to address the etiology of the Veteran’s hypertension. The examiner was asked to specifically address whether the Veteran’s hypertension was caused or aggravated by his service-connected CAD. In the resulting September 2019 report, a VA examiner concluded that it was less likely than not that the Veteran’s hypertension was due to his service-connected CAD. In support of this conclusion, the examiner simply concluded there was no documentation to link the two and instead discussed the Veteran’s prescribed CAD medication and its effects on lowering the Veteran’s blood pressure. There was no explanation of the cause of the Veteran’s hypertension, or whether it was aggravated by CAD. In its August 2020 remand, the Board instructed the Agency of Original Jurisdiction (AOJ) to arrange for an addendum opinion from the September 2019 examiner. Again, the examiner was asked to specifically address whether the Veteran’s hypertension was caused or aggravated by his service-connected CAD. The examiner was asked to provide a clear rationale consistent with the evidence of record. As to whether the Veteran’s hypertension was caused by his service-connected coronary artery disease, the examiner simply repeated the rationale from the September 2019 examination that “[t]here is no evidence or documentation to relate his CAD as the causative etiology of his hypertension.” The explanation of whether the Veteran’s hypertension was aggravated by CAD was only marginally better. The examiner stated that there is no documentation that the Veteran’s hypertension was exacerbated by his CAD and that his blood pressure has always been stable and well controlled. The Board notes that the absence of contemporaneous records does not preclude granting service connection for a claimed disability. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an “absolute bar” to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) (“Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms”). The Board finds the September 2020 examination inadequate. Once VA provides an examination in a service connection claim, the examination must be adequate, or VA must notify the veteran why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 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. Appl 120, 124 (2007). Here, the examiner again did not address a nexus, if any, between the Veteran’s service-connected CAD and his hypertension. Rather, he addressed the fact that the Veteran took medication for treatment of CAD without discussing etiology. Therefore, the Board finds that the examination does not substantially comply with the Board’s remand order. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (Board remand confers a right on a claimant to compliance with the remand order). In the instant case, rather than remand for yet another medical opinion, the Board will resolve reasonable doubt in favor of the Veteran and award service connection for hypertension as due to the Veteran’s service-connected CAD. In this regard, the Board notes that the first mention of the Veteran’s hypertension is an August 2011 VA treatment note that indicates mild hypertension. His CAD was diagnosed in follow-up testing in September 2011. Overall, given the close proximity of the two diagnoses and the VA’s inability to provide an adequate medical opinion, the Board finds that entitlement to service connection for hypertension is therefore warranted on a secondary basis. The claim is granted. R. FEINBERG Veterans Law Judge Board of Veterans’ Appeals J. Morgan, Attorney for the Board Department of Veterans Affairs 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.