Citation Nr: 21068482 Decision Date: 11/10/21 Archive Date: 11/10/21 DOCKET NO. 14-34 699A DATE: November 10, 2021 REMANDED Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 1968 to June 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2013 rating decision of the Department of Veterans' Affairs (VA) Regional Office (RO). In a February 2019 decision, the Board denied the Veteran's claim of entitlement to service connection for hypertension. The Veteran timely appealed. In February 2020, the Court of Appeals for Veterans Claims (CAVC) vacated the Board's decision and remanded the issue for further evidentiary development. Specifically, CAVC determined that the Board relied on an expert opinion that did not explain if the Veteran's hypertension began during service or within the presumptive period after service. Additionally, CAVC determined that the Board did not provide adequate reasons and bases for discounting the Veteran's testimony and statements that he was initially diagnosed with hypertension in September 1970 and was prescribed hypertension medication. In response to the February 2020 CAVC remand, the Board has remanded the claim twice for additional evidentiary development. In the most recent July 2021 Board remand, the Board detailed the Veteran's lay contentions and the objective medical evidence of record. Based on the information outlined in the remand, the Board found that an additional, clarifying medical opinion was required. Accordingly, the Board remanded the appeal, requesting an opinion from a qualified doctor of internal medicine. The Board specifically requested that the AOJ document for the record the opining examiner's qualifications as a doctor of internal medicine. Upon remand, in August 2021, Dr. J.G. provided a negative nexus based on the evidence of record. However, documentation regarding Dr. J.G.'s qualifications as a doctor of internal medicine is not of record. As it is unclear whether the opining physician specializes in internal medicine, remand is necessary to obtain all appropriate documentation regarding the qualifications of the VA examiner. If it turns out Dr. J.G. does not specialize in internal medicine, the AOJ should obtain an opinion from an appropriately qualified examiner. Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding when a remand is issued, the Veteran is entitled, as a matter of law, the right to compliance with the remanded order). The matters are REMANDED for the following action: 1. Document for the record whether Dr. J.G., the August 2021 opining examiner, meets the qualifications of a doctor of internal medicine. 2. If Dr. J.G. is NOT a doctor of internal medicine, forward the Veteran's claims file to a qualified Doctor of Internal Medicine for an opinion addressing the onset of his diagnosed hypertension. The AOJ must document for the record that the examiner meets the qualifications of a doctor of internal medicine. The examiner should review the claims file, to include the July 2021 Board remand, which details the lay and medical evidence of record. The examiner should accept, arguendo, that the Veteran was prescribed a diuretic in September 1970 due to a blood pressure reading of 190/10, that the Veteran recalls taking hypertensive medications consistently since 1987, and that the available medical records first reflect a prescription of Zestoretic in June 2001. The examiner should discuss whether a diagnosis of hypertension and prescription of a diuretic based on one doctor visitation with a blood pressure reading of 190/110 in September 1970, when viewed in the context of the entirety of the record, is deemed a medically valid diagnosis given the criteria that a diagnosis of hypertension should be based confirmed by readings taken two or more times on at least three different days, and whether the prescription of a diuretic with a blood pressure reading 190/110 would be deemed appropriate medical treatment given the medical treatise articles describing such a reading as constituting a hypertensive emergency. The examiner should further discuss whether there is any medical reason to accept or reject the Veteran's belief that he has manifested hypertension since 1970 based on his recollection of being prescribed a diuretic due to a blood pressure reading of 190/110, but not being on steady hypertensive medications until the late 1980s. In providing the opinion, the examiner's attention is directed towards the following evidence: The Veteran's June 1968 entrance examination noting his blood pressure was 128/74, and his May 1970 separation examination reflected blood pressure of 144/78; An October 1970 VA examination reflecting a blood pressure reading of 130/82 in light of claimant's recollection of being on a diuretic at the time; The medical records from Dr. B. dating back to 1998 which includes a medication list dating back to 1999 and lists a "Date Started" of Zestoretic in June 2001; The August 2014 letter from the Veteran's private physician, Dr. H.B., who has treated the Veteran since 1980 and states that the Veteran has been treated for hypertension; The September 2018 expert medical opinion determining the Veteran's hypertension is not related to in-service salt tablet consumption, and determining it is most likely genetic in nature; and The Veteran's recollection that he was first diagnosed with hypertension in September 1970 based on a blood pressure reading of 190/110, that he was prescribed a diuretic at the time, which he took but did not refill due to finances and being treated with medications for hypertension since the late 1980s in light of the fact that he was first prescribed Zestoretic in June 2001; and The April 2021 VA examiner assessment that, if the Veteran had had significant hypertension since 1970, one would expect to see end organ damage such as chronic kidney disease. The examiner is reminded that the lack of evidence of treatment is cannot be the sole basis for a negative nexus. Buchanan v Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (lack of contemporaneous medical records does not serve as an absolute bar to the service connection claim). The need for in-person examination or interview is left to the discretion of the examiner. T. MAINELLI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Orie, 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.