Citation Nr: 21068560 Decision Date: 11/10/21 Archive Date: 11/10/21 DOCKET NO. 16-26 320 DATE: November 10, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to the Veteran's service-connected asthma with chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1973 to December 1973. This matter comes before the Board of Veteran's Appeal (Board) on appeal from a July 2014rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran selected a hearing with a Veterans Law Judge on his June 2016 Notice of Disagreement. In November 2016 and November 2020, the Veteran testified at two Board hearings before the undersigned Veterans Law Judge. The transcripts of the hearings are of record. In May 2017, August 2018, and July 2021, the Board previously remanded this matter for new VA examinations and medical opinions. The case has now returned to the Board for appellate review and, although it again regrets further delay, the Board finds that additional remand is required. Service connection for hypertension is remanded. After reviewing the evidence of record, the Board that there has not been substantial compliance with the Board's prior remand directives. Accordingly, another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). Specifically, pursuant to the July 2021 Board remand, the RO was instructed to schedule the Veteran's examination with a cardiologist or pulmonologist to provide the requested opinion. However, the Veteran's August 2021 VA examiner was an internal medicine doctor which does not comply with the Board's July 2021 remand directives. Therefore, the Board finds that remand is necessary. Additionally, the Board finds that the August 2021 VA medical opinion is inadequate. Specifically, the August 2021 examiner opined that the Veteran's hypertension disability is less likely than not proximately aggravated beyond its natural progression by asthma with COPD and OSA. See August 2021 VA Medical Opinion. Additionally, the examiner distinguished between primary and secondary hypertension and explained that primary hypertension has no identifiable cause. Id. In contrast to primary hypertension, the examiner conceded that decongestants and pain medication can lead to secondary hypertension. Id. However, the examiner found that it was not possible to attribute the aggravation of hypertension to any of any group or risk facts without speculating. In an addendum opinion, the examiner explained that speculation would not be possible because there are facts that simply cannot be determined, in this case namely the actual aggravating factors of the hypertension due to the myriad of possible causes. Therefore, he could not speculate and determine aggravation of any kind by the medications taken by the Veteran. However, the Board finds that this opinion is inadequate. The examiner explained the difference between primary hypertension and secondary hypertension, but failed to explain which type of hypertension the Veteran has. The examiner also acknowledged that decongestants lead to secondary hypertension, but failed to explain why in this case, the Veteran's decongestants did not cause or lead to his hypertension disability. However, it is unclear if the examiner could not determine aggravation by the Veteran's medication but failed to explain why, especially in light of acknowledging the decongestants and pain medication may lead to secondary hypertension. Moreover, in general, the examiner did not adequately explain why the Veteran's hypertension was not caused by his respiratory conditions. Based on the foregoing deficiencies, the Board finds that the August 2021 VA medical opinion is inadequate for adjudicative purpose. See Nieves-Rodriguez, 22 Vet. App. 295, 304 (2008); see also Stegall, 11 Vet. App. at 268. Accordingly, the Board finds that an addendum opinion is warranted. The VA medical opinion should address whether the Veteran's asthma and COPD with OSA disability caused and/or aggravated the Veteran's hypertension disability. The VA medical opinion should also address whether the Veteran's respiratory medications aggravated his hypertension disability. Lastly, the examination must be conducted by a cardiologist and pulmonologist. In ordering a remand in the instant case, the Board is not making a preliminary formal finding as to the credibility of the Veteran's lay reports. Rather, the Board is merely requesting that the examiner on remand consider the Veteran's own descriptions of the history of his hypertension disability. See Smith v. Wilkie, 32 Vet. App. 332, 338-39 (2020). The matters are REMANDED for the following action: 1. Send the Veteran's claims file to a VA cardiologist or pulmonologist for the purpose of obtaining an opinion regarding the etiology of his hypertension. If the requested specialist is not available to provide the opinion, the AOJ must explain the reasons that this is so. After a review of the claims file, the specialist should respond to the following: (a.) Is it at least as likely as not (50 percent probability or more) that the Veteran's hypertension was caused by his asthma with COPD and OSA? Please explain why or why not. (b.) If the Veteran's hypertension is not caused by his service-connected asthma with COPD and OSA, is it at least as likely as not (50 percent probability or more) that the Veteran's hypertension was aggravated by his asthma with COPD and OSA? Here, aggravated means worsened beyond the natural progression of the condition. The examiner's opinion should reflect consideration of the Court's holding in Ward v. Wilkie that aggravation need not be permanent in nature. Ward v. Wilkie, 31 Vet. App. 233, 241-42 (2019); 38 C.F.R. §3.310(b). (c.) Please comment on whether the Veteran's respiratory medication, including decongestants bronchodilators, and pain medication, aggravated the Veteran's hypertension disability. See November 2020 Board Hearing Trans. p. 9. Here, aggravated means worsened beyond the natural progression of the condition. Significantly, aggravation need not be permanent in nature. The examiner's opinion should reflect consideration of the Court's holding in Ward that aggravation need not be permanent in nature. Ward, 31Vet. App.233, 241-42 (2019); 38C.F.R. §3.310(b). (d.) In providing the opinion requested in Part (c), please determine whether the Veteran has primary or secondary hypertension. Please refer to the August 2021 VA Medical Opinion's distinction of the two types of hypertension. A discussion of the underlying reasons for any opinion expressed must be included in your report, to include reference to pertinent evidence of record and medical literature or treatises where appropriate. If you cannot provide the requested opinion without resorting to speculation, please expressly indicate this and state why that is so (e.g. lack of sufficient information/evidence, the limits of medical knowledge, etc.). S.C. Krembs Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Foster, Associate 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.