Citation Nr: 21068248 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 17-46 388 DATE: November 9, 2021 REMANDED Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1984 to December 1986, with period of service in the Army Reserves from January 1991 to October 1991. The Veteran testified before the undersigned Veterans Law Judge during an August 2018 Travel Board Hearing. The transcript of the hearing is in the claims file. This matter was previously remanded by the Board of Veterans Appeals (Board) in June 2018, September 2019, October 2020, and March 2021 for additional development. It now returns for further appellate review. 1. Entitlement to service connection for hypertension is remanded. Unfortunately, the Board finds another remand is necessary in this case. The Board is aware this matter was remanded four times before (and regrets the delay in final adjudication inherent with yet another remand). However, the response provided has been inadequate to comply with the previous Board remands, and corrective action remains necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (A remand by the Board confers on the claimant, as a matter of law, a right to compliance with the remand orders.) As noted in the introduction, this matter was most recently remanded in March 2021. The Board remanded the claim to ensure compliance with the October 2020 Board remand. Specifically, the Board noted that the October 2020 remand directed the VA examiner to address the instances of elevated blood pressure readings noted in the Veteran's STRs and whether his current hypertension was related to the elevated readings. See March 2021 Board Remand. The Board observed that the November 2020 VA examiner failed to address the elevated blood pressure readings as directed in the October 2020 Board remand. Consequently, the Board remanded the claim for compliance with the October 2020 Board remand. Id. Specifically, the Board asked the VA examiner to address the notations of elevated blood pressure readings documented in the Veteran's service treatment records (STRs) in September 1983 and June 1987, or the Veteran's 1991 report of frequent or severe headaches during active service. Id. Pursuant to the March 2021 Board remand, the Veteran was provided a VA examination in June 2021. The examiner confirmed a diagnosis of hypertension and opined that it was less likely than not that the Veteran's hypertension was related to a specific exposure during his service in Southwest Asia. See June 2021 VA General Medical Gulf War Disability Benefits Questionnaire (DBQ). The examiner did not provide any rationale to support his conclusion. The examiner also provided an additional nexus opinion in June 2021. Specifically, the examiner opined that the Veteran's hypertension was less likely than not related to active service. See June 2021 VA Medical Opinion DBQ. The examiner stated that there was no evidence of hypertension noted in the Veteran's STRs and "the highest I could find was on page 399 from September 17, 1991 with a BP of 130/70. There aren't enough readings at the time...." Id. However, the examiner did not address the other notations of elevated blood pressure readings including the September 1983 STR, which showed BP of 140/88 and a June 1987 STR, reflecting BP of 130/88. Additionally, the examiner did not address the September 1991 Report of Medical History in which the Veteran stated he did not know if he had high blood pressure. See September 1991 Report of Medical History, in STR-Medical. As such, the Board finds that the June 2021 VA medical opinion does not comply with the October 2020 and March 2021 Board remands, which necessitates another remand pursuant to See Stegall v. West, 11 Vet. App. 268, 271. The Board also finds that the June 2021 VA examiner did not provide a reasoned analysis to support his negative nexus opinion. Specifically, the examiner noted the "Veteran began with headaches associated with HTN back in 1994." See June 2021 VA Hypertension DBQ. Yet, the examiner opined that the Veteran's hypertension was less likely than not proximately due to his service-connected migraine headaches. See June 2021 Medical Opinion DBQ. The examiner reasoned that there was no evidence to support that migraine headaches cause Veteran's hypertension. The Board finds that this rationale is inadequate to the extent it is conclusory and does not provide any supporting data or reasoned analysis for the examiner's conclusion. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007)(A medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two.) Notably, the examiner did not fully address the Veteran's contention that his hypertension was associated headaches. Additionally, the Board finds that the examiner did not address whether the Veteran's hypertension was aggravated by the Veteran's service-connected migraine headaches. See El Amin v. Shinseki, 26 Vet. App. 140 (2013)(A medical opinion regarding secondary service connection must address both causation and aggravation.) Notably, the Veteran's representative argued that the June 2021 VA opinion is inadequate because the examiner "provided a bald and conclusory response to the Board's medical conditions without a well-supported medical rationale." See October 2021 Appellate Brief. The Board agrees with the arguments raised in the October 2021 Appellate Brief regarding the adequacy of the June 2021 medical opinion and finds that the June 2021 VA medical opinion fails to comply with the October 2020 and March 2021 Board remand. Accordingly, the June 2021 addendum medical is inadequate for adjudication purposes. As such, a remand is necessary to obtain an adequate VA opinion regarding the nature and etiology of the Veteran's claimed hypertension. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Importantly, the Board finds that this issue poses a medical problem of such obscurity or complexity that an advisory opinion from an independent medical expert (IME) from an examiner with experience in treating heart and blood vessel disabilities is required. See 38 U.S.C. § 5109 ; 38 C.F.R. § 3.328. Specifically, multiple VA opinions have been unable to adequately answer the question of the etiology of the Veteran's hypertension. The Agency of Original Jurisdiction (AOJ) must follow its established procedures for requesting an advisory opinion furnished by a medical school, university, or clinic on remand. The matters are REMANDED for the following action: 1. Obtain an advisory medical opinion from an independent medical expert preferably from a physician with a specialty in cardiology or with experience in treating or diagnosing hypertension pursuant to 38 U.S.C. § 5109 and 38 C.F.R. § 3.328. The AOJ must follow its established procedures for requesting such an advisory opinion. The entire claims file must be provided to, and reviewed by, the physician. If the physician determines it to be necessary, and examination should be scheduled and any indicated tests, studies, or evaluations should be performed. 2. The Veteran's entire claims file, to include a copy of this decision, should be made available to the physician. Following a complete review of the record, the physician is asked to determine if an examination of the Veteran is necessary. 3. The physician is asked to: (a.) If an examination is conducted, obtain the Veteran's detailed lay history, including onset and progression of symptomatology. (b.) Opine as to whether it is at least as likely as not (50 percent or better probability) that the Veteran's hypertension: i. had its onset in service or manifested to a compensable degree within one year of service; or ii. is related to elevated blood pressure readings documented in the Veteran's STRs in September 1983 and June 1987, or the Veteran's 1991 report of frequent or severe headache during active service; or iii. is Veteran's documented elevated blood pressure readings documented in the Veteran's STRs in September 1983 and June 1987, or the Veteran's 1991 report of frequent or severe headache, were earlier manifestations of his currently diagnosed hypertension; or iv. is the Veteran's current hypertension related to or caused by the Veteran's exposure to environmental hazards during his deployment in Southwest Asia the Gulf War? v. is the Veteran's current hypertension proximately at least as likely as not (i.e., a 50 percent or greater probability) due to or caused by his service-connected migraine headaches? vi. whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's hypertension underwent an incremental increase (aggravated), regardless of permanence, by his service-connected migraine headaches. The term incremental increase in disability means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. Moreover, any incremental increase in disability need not be permanent. The term at least as likely as not does not mean within the realm of medical possibility. Rather, it means that the weight of the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion (e.g., etiology) as it is to find against the conclusion. Any opinion expressed by the physician should be accompanied by a complete rationale. If medical literature is relied upon in rendering a determination, the physician should identify and specifically cite each reference material utilized. If the physician is unable to offer an opinion without resort to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. The physician is reminded that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinions. The physician is also reminded that noting that a condition did not manifest in service as the sole basis for forming a negative nexus opinion, without additional explanation, will not be adequate. 4. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL. (Continued on the next page) IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE CORRECTIVE ACTION MUST BE IMPLEMENTED. YVETTE R. WHITE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Lilly, 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.