Citation Nr: 21071826 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 16-39 483 DATE: December 1, 2021 REMANDED Entitlement to service connection for hypertension (HTN), to include as secondary to diabetes mellitus, type two (DM-II) with peripheral neuropathy of the bilateral upper and lower extremities, is remanded. INTRODUCTION The Veteran served honorably on active duty in the United States Army during the Peacetime and Vietnam Era, from March 1964 to March 1966, including service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2014 Rating Decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Guaynabo, Puerto Rico. In October 2017, the Board denied the Veteran's claim on the merits and, thereafter, he appealed to the United States Court of Appeals for Veterans Claims (Court). Pursuant to a Joint Motion for Partial Remand (JMPR) agreed upon by the parties, the Court entered its August 2018 Order remanding the matter for action consistent with the terms of the JMPR. When this matter came before the Board most recently in September 2021, it was remanded for additional development, specifically, to afford the Veteran another VA examination and obtain a medical nexus opinion adequate for adjudication purposes. The additional development has been completed and the matter returns to the Board for further appellate review. The Board also observes there is a separate appeal stream stemming from a different RO (i.e., St. Petersburg, Florida) and, pursuant to the Board's internal procedures, the two appeals cannot be merged, and separate decisions are required. While further delay is regrettable, for the reasons set forth below, the Board finds remand is again required. Finally, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2). REASONS FOR REMAND Entitlement to service connection for HTN, to include as secondary to DM-II with peripheral neuropathy of the bilateral upper and lower extremities, is remanded. Pursuant to the Board's September 2021 remand directives, the Veteran underwent a VA examination in September 2021. The VA examiner opined that the Veteran's HTN "is less likely than not ... proximately due to or the result of the Veteran's service connected condition," and is not "at least as likely as not aggravated beyond its natural progression" by same. According to the VA examiner, because the Veteran's urinary microalbumin has remained normal, meaning "that the kidney is not affected by [DM-II]," she concluded that, "[HTN] can not [sic] be attributed to [DM-II]." Further, the VA examiner opined that, "[t]he etiology of [HTN] in this Veteran is genetic factors, essential [HTN]." For the following reasons, the Board finds the VA examination report inadequate for adjudication purposes and, consequently, there has not been substantial compliance with the Board's prior remand directives such that remand is again required. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stegall v. West, 11 Vet. App. 268 (1998). The Board finds the VA examiner's abbreviated opinion rationale that, absent diabetic nephropathy (i.e., kidney disease caused by diabetes) HTN cannot be attributable to DM-II, without more, is conclusory in nature. Likewise, the VA examiner's rationale that the Veteran's HTN is due to "genetic factors," without identifying such factors or discussing their causative relationship, is also conclusory in nature. See Miller v. West, 11 Vet. App. 18, 22 (2007) (a bare conclusion, even one reached by a healthcare professional, is not probative without a factual predicate in the record). The VA examiner's rationale also fails to report and consider any statements to her by the Veteran regarding HTN symptomology, or lack thereof, such as when initially manifested or progressed. See Dalton v. Peake, 21 Vet. App. 23 (2007) (noting that a medical opinion which does not consider the Veteran's reports of symptoms and history, even if recorded in the course of the examination, is inadequate). Finally, while the Board's prior remand directed the VA examiner to "consider medical studies discussing the correlation between [DM-II] and HTN," and cited "Type 2 diabetes mellitus and hypertension: An update (nih.gov)" by G. Lastra, et. al., "discussing the Framingham Heart Study," the examination report is devoid of any such consideration. Based upon the foregoing, the Board is unable to conclude that the VA examiner applied valid medical analysis to the significant facts of this particular case, and finds the opinion lacks a clear conclusion with supporting data and a reasoned medical explanation connecting the two. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (a medical opinion is most probative if it is factually accurate, fully articulated, and based upon sound reasoning). As such, remand for another VA examination and procurement of a medical nexus opinion with rationale adequate for adjudication purposes is required. Accordingly, this matter is REMANDED for the following action: Schedule the Veteran for an in-person VA examination with a physician who has not previously offered an opinion in this matter and possessing the necessary expertise to fully assess and provide an opinion regarding the nature, severity, and likely etiology of the Veteran's HTN, to include as secondary to a service-connected disability or disabilities. The examiner must obtain a full history from the Veteran. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, such as observable symptomology and functional limitations. All pertinent symptomology, including when initially manifested and any progression, must be elicited from the Veteran and reported in detail. Based upon a review of all pertinent evidence in the Veteran's claims file including medical treatment and prior examination records, lay statements, and the examination results, the examiner must offer an opinion based upon an accurate medical history with clear conclusions and supporting data as to: (a.) Whether it is at least as likely as not (i.e., 50 percent probability or greater) the Veteran's HTN is proximately due to, related to, or otherwise etiologically associated with his service-connected disabilities including, but not limited to, DM-II with bilateral upper and lower extremity peripheral neuropathy or prostate adenocarcinoma. (b.) Whether it is at least as likely as not (i.e., 50 percent probability or greater) the Veteran's HTN has been aggravated by his service-connected disabilities including, but not limited to, DM-II with bilateral upper and lower extremity peripheral neuropathy or prostate adenocarcinoma. The examiner is advised that aggravation does not require a permanent worsening of the condition, but rather, any incremental increase in disability attributable to the service-connected disability, i.e., any additional impairment of earning capacity that is above the degree of disability existing before the increase. See Ward v. Wilkie, 31 Vet. App. 233 (2019). In offering the above opinions, the examiner must consider, discuss, and reconcile as necessary all pertinent lay and medical treatment and examination evidence of record, as well as Type 2 diabetes mellitus and hypertension: An update, G. Lastra, et. al., 43 Endocrinology Metabolic Clinic North America 1, 103-122, March 2014 (nih.gov). The examiner is advised that the mere absence of evidence does not equate to unfavorable evidence. The Veteran's lay statements and reports of onset and symptomology must be considered and discussed. A complete and thorough rationale for all opinions expressed, with references to pertinent evidence of record and, as warranted, relevant medical literature must be provided. T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Worsham, Attorney Advisor 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.