Citation Nr: 21063662 Decision Date: 10/15/21 Archive Date: 10/15/21 DOCKET NO. 18-48 306 DATE: October 15, 2021 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to a rating in excess of 10 percent for gastroesophageal reflux disease (GERD) is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1962 to December 1992. In October 2021, a Board hearing was held before the undersigned Veterans Law Judge (VLJ). 1. Entitlement to service connection for hypertension is remanded. In October 2017, the Veteran was provided a VA examination and medical opinion to assess the etiology of his hypertension. The examiner opined that the Veteran's hypertension was less likely than not proximately due to or the result of the Veteran's service-connected back disorder and explained that medical literature suggests that NSAIDs may cause or worsen hypertension, but it may be a stretch to state that hypertension was due to his medications to treat back pain. The examiner indicated further that consumption of pain medication did not really cause hypertension. The Board, however, finds that the October 2017 VA medical opinion is insufficient for rating purposes. Chiefly, while the examiner appears to have discussed whether the Veteran's hypertension was caused by his service-connected back disorder, to specifically include associated medication therapy, the VA examiner did not address the aggravation aspect of secondary service connection. As such, the Board finds that remand is warranted for a new VA medical opinion consistent with the directives herein. The Board also notes that in a May 2020 Appellate Brief, the Veteran's representative generally contended that the Veteran's pain from his service-connected disabilities and GERD may trigger elevations in his blood pressure. In November 2020, the Veteran also claimed that his hypertension was related to his service-connected myelodysplastic syndrome (MDS). At the October 2021 hearing, the Veteran explained that when he undergoes chemotherapy for his service-connected MDS he must discontinue both his use of NSAIDs and anti-hypertensive medication, which aggravates his hypertension. On remand, the VA examiner must also address secondary service connection with regard to GERD and MDS as well. 2. Entitlement to a rating in excess of 10 percent for GERD is remanded. The Veteran was last afforded a VA examination to evaluate his GERD in October 2017. At the October 2021 Board hearing, the Veteran testified that his reflux now affected his sleep, his voice when the acid traveled up his throat, and he also experienced at times pain below the breast bone. Such evidence suggests a worsening of the Veteran's symptomatology since his last VA examination. Accordingly, VA's duty to assist necessitates that this claim be remanded to schedule a new VA examination. The matters are REMANDED for the following actions: 1. Obtain a VA medical opinion from an appropriate examiner to determine the nature and etiology of the Veteran's hypertension. Physical examination of the Veteran may be scheduled/conducted if deemed necessary. The claims folder (including a copy of this remand) must be provided to and reviewed by the examiner as part of the medical opinion. a) The examiner must opine as to whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's hypertension is caused or aggravated by his service-connected disabilities, to include his lumbar spine disorder, GERD, and MDS. Aggravation in the secondary service connection context is defined as any increase in disability. In rendering the above opinions, the VA examiner must specifically consider and discuss the Veteran's testimony regarding the fact that he has to discontinue his hypertension medication for his MDS chemotherapy treatment and the claims that his back pain medication, to include Celebrex and Motrin, and his GERD affect his hypertension. The examiner is advised that the Veteran is competent to report his symptoms/history and that such reports must be acknowledged and considered in formulating any opinion. If his reports are discounted, the examiner should provide a reason for doing so. A rationale for all requested opinions shall be provided. The rationale must include a discussion of the underlying medical principles specific to the facts of this case and not simply reference generic medical literature. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner 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. 2. Obtain a VA examination from an appropriate examiner to determine the nature and severity of the Veteran's service-connected GERD. The examiner must review pertinent documents in the Veteran's claims file in conjunction with the examination. All indicated studies should be completed. All findings must be fully reported. a) The examiner is instructed to discuss the presence (including frequency and severity) or absence of epigastric distress, dysphagia, pyrosis, regurgitation, substernal or arm or shoulder pain or other pain, vomiting, material weight loss, hematemesis or melena, and anemia. b) The examiner must state whether the combination of the applicable symptoms is productive of either severe impairment of health or considerable impairment of health. The examiner is advised that the Veteran is competent to report his symptoms/history and that such reports must be acknowledged and considered in formulating any opinion. If his reports are discounted, the examiner should provide a reason for doing so. A rationale for all requested opinions shall be provided. The rationale must include a discussion of the underlying medical principles specific to the facts of this case and not simply reference generic medical literature. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner 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. A. ISHIZAWAR Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Metzner, Paul 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.