Citation Nr: 21063462 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 10-24 321 DATE: October 14, 2021 REMANDED Entitlement to service connection for hypertension as secondary to service-connected diabetes mellitus and/or coronary artery disease (CAD), is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1968 to August 1971. This case comes before the Board of Veterans' Appeals (Board) on appeal of a March 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran contends his hypertension is secondary to his service-connected diabetes mellitus. See April 2009 VA Form 21-4138, Statement in Support of Claim. In a November 2020 rating decision, the Veteran was granted service connection for CAD. Since the Veteran is now service connected for CAD, the Board finds that it is appropriate to expand the scope of the Veteran's claim to include entitlement to service connection for hypertension as secondary to service-connected diabetes and/or CAD. The Veteran was afforded a VA medical opinion in October 2020 pursuant to a June 2018 Board remand. The October 2020 VA examiner opined that the condition claimed (hypertension) was less likely than not proximately due to or the result of the Veteran's service-connected condition (diabetes). The examiner's statement in the rationale was that the Veteran's hypertension was diagnosed in 2003 and diabetes mellitus in 2006. The Board remanded this matter in April 2021. The Board found that the October 2020 examiner considered aggravation. The Board also found that the October 2020 VA examiner did not address the significance of microalbuminuria noted in the July 2009 VA examination. The Board inadvertently omitted this instruction from the June 2018 remand directives. As a result of the April 2021 Board remand, the Veteran was afforded a VA examination and opinion in August 2021. The examiner reviewed the Veteran's recorded and conducted an in-person examination. The examiner addressed the absence of urine microalbuminuria. The examiner ultimately opined that the claimed hypertension condition is less likely than not proximately due to or the result of the Veteran's service-connected disability, to include natural progression by service-connected diabetes mellitus. In the examiner's rationale, he stated that there was no evidence in the records, literature, or history to support that the current diagnosed hypertension conditions are due or aggravated by the Veteran's natural progression by service-connected diabetes mellitus. The Board finds that the October 2020 and April 2021 opinions lack an adequate rationale as to the Veteran's service-connected diabetes causing or aggravating the Veteran's hypertension disability. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). The October 2020 opinion only included language that the Veteran's hypertension was not proximately due to or the result of the Veteran's service-connected diabetes. The examiner stated in the rationale that the Veteran's hypertension was diagnosed three years prior to the diagnosis of diabetes. Equally important, the April 2021 examiner found it was less likely than not that the Veteran's hypertension was proximately due to or the result of the Veteran's service-connected disability, to include natural progression by service-connected diabetes mellitus. The language used in both opinions is not the standard for secondary service connection. See Ward v. Wilkie, 31 Vet. App. 233 (2019). Additionally, the rationales from the October 2020 and April 2021 opinions are inadequate because the examiners used a conclusory statement that aggravation is not supported by the record. Unfortunately, the Board finds the October 2020 and April 2021 opinions inadequate, and another remand is required. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The matter is REMANDED for the following action: After undertaking any additional development deemed necessary, forward the Veteran's claims file to a qualified medical professional in order to obtain a record review and opinion as to the etiology of the Veteran's hypertension. The claims file, to include a copy of all Board remands and all VA examinations and opinions, must be made available to and be reviewed by the examiner. The examiner must indicate that the claims file was reviewed in conjunction with the new opinion. The examiner should determine: a.) Whether it is it at least as likely as not (at least an approximate balance of positive and negative evidence) that the Veteran's hypertension was caused or aggravated by the Veteran's service-connected diabetes and/or coronary artery disease. The Board notes that causation and aggravation are independent concepts and need separate findings and rationales. Atencio v. O'Rourke, 30 Vet. App. 74 (2018). The examiner is reminded that there is NO requirement of "permanent aggravation"; rather, the Board seeks to determine whether there was aggravation in a more general sense. b.) The examiner is also requested to opine on the significance of the absence of microalbuminuria (referenced by the July 2009 VA examiner) as it pertains to the Veteran's hypertension. A rationale is necessary for all opinions, in a typewritten report. A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Hetman 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.