Citation Nr: 21007505 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 15-29 402 IDATE: February 9, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus type II, is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1969 to September 1971, and June 1981 to January 1984. The Veteran served in Vietnam from March 1971 to August 1971. He had additional service in the Reserves. This appeal comes before the Board of Veterans’ Appeals (Board) from a June 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2018, the Board remanded the claim for further evidentiary development. Entitlement to service connection for hypertension. The Veteran contends that he developed hypertension due to or aggravated by his service-connected diabetes mellitus. See NOD (July 2012). At his September 2020 VA examination, he stated that he had had high blood pressure since service. See C&P Exam (September 2020). A remand by the Board imposes upon the Secretary of VA a concomitant duty to ensure compliance with the terms of the remand. Where remand orders of the Board are not complied with, the Board errs in failing to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). As an initial matter, the Board notes that, in September 2018, the claim was remanded for a new VA examination and medical opinion as the June 2012 VA examination was found to be inadequate for rating purposes. Although a September 2020 VA examination and medical opinion were obtained, the medical opinion is inadequate as it did not fully answer the Board’s question. It is noted that a medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record. See Stefl v. Nicholson, 21 Vet. App. 102, 124-25. Also, “[A] medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two.” Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Here, the Board is unable to discern the essential rationale for the opinion. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). First, while the September 2020 opinion contains clear conclusions with some supporting data, it lacks a reasoned medical explanation connecting the two. For example, the opinion concludes that the Veteran’s hypertension is less likely than not incurred in or caused by the claimed in-service injury, event or illness because of lack of records of high blood pressure while in service and normal findings at the discharge examination. See C&P Exam (September 2020). However, it makes no attempt to connect the lack of treatment or annotated diagnoses to its conclusion. See Nieves-Rodriguez, 22 Vet. App. at 301. In this case, the medical opinion provides no clear finding as to the date or circumstances of the onset of the Veteran’s hypertension. Moreover, it provides no explanation as to the significance, or lack thereof, of any absence of annotated high blood pressure during service or at discharge. Instead, the opinion discussed other factors that could have caused the Veteran’s hypertension, to include age, weight and ethnicity, but provided the Board with no reasoned rationale connecting the causative factor to the Veteran’s current hypertension. Nieves-Rodriguez, 22 Vet. App. at 301. It is noted that generic and conclusory statements are insufficient to satisfy medical evidence of nexus requirement. See Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996). In other words, the Board may not rely on a medical examiner’s conclusory statements if they lack supporting analysis. Instead, a medical opinion must be based upon consideration of the Veteran’s prior medical history and examinations and also describe the disability, if any, in sufficient detail so that the Board’s evaluation of the claimed disability will be a fully informed one. Thus, the absence of a meaningful discussion of the Veteran’s prior medical history does not show awareness of seemingly relevant facts and therefore casts doubt on the medical opinions’ foundation for the negative linkage opinion. Second, the September 2020 medical opinion, while noting it, does not address the Veteran’s contention that he has experienced high blood pressure since service. See McKinney v. McDonald, 28 Vet. App. 15, 30-31 (2016) (“the VA examiner’s failure to consider [a veteran’s] testimony when formulating her opinion renders that opinion inadequate”). Instead, the opinion relied on the absence of annotated treatment during service. If there is a medical basis to support or doubt the history provided by the Veteran, the clinician should provide a fully reasoned explanation. Third, the September 2020 VA opinion was based, at least partly, on an inaccurate factual premise and presents with internal incongruities. See Reonal v. Brown, 5 Vet. App. 460, 461 (1993) (an opinion based on an inaccurate factual premise has no probative value). First, the examination continuously refers to the Veteran’s reports of the date of onset of his hypertension as 10 years prior to the examination (2010), while also noting that the Veteran reported having high blood pressure since service. However, the record also shows that the Veteran was diagnosed with hypertension in 2004. See VA Examination (June 2012). The opinion then indicated that “Diabetes can be a condition that causes hypertension. But since the veteran stated he has only been diabetic for the last 10 years, the diabetes could not be the cause.” Id. In other words, the opinion’s conclusion was based on an incorrect date of diagnosis. Fourth, the opinion manifests as inconclusive in stating that “Diabetes can be a condition that causes hypertension.” See Hood v. Shinseki, 23 Vet. App. 295, 298-99 (2009) (stating a medical examiner’s use of ambivalent or noncommittal phrases “should have signaled to the Board that the medical opinion was speculative and of little probative value”); see also Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinion expressed in terms of “may” also implies “may or may not” and is too speculative to establish medical nexus); Warren v. Brown, 6 Vet. App. 4, 6 (1993) (doctor’s statement framed in terms such as “could have been” is not probative); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). The opinion made no attempt to adequately explain how this statement applies to the Veteran’s particular circumstances. Fifth, the Board finds that the September 2020 VA medical opinion is inadequate because it does not fully address whether hypertension is proximately due to or aggravated by his service-connected diabetes. 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995). The opinion does not provide clear separate findings and rationales relating to causation and aggravation to support the conclusion reached. See Atencio v. O’Rourke, 30 Vet. App. 74 (2018). Further, the Board observes that the dates noted in the opinion conflict with the evidence of record as stated above; and the significance of the onset of hypertension prior to diabetes is neither explained nor does it have any significance in establishing secondary service connection under the first (causation) or second prong (aggravation) discussed. See Stegall, supra. Given that the VA medical opinion is absent of any meaningful discussion or adequate findings, the Board finds that it may not rely upon it in its present form. Where VA provides an examination or obtains an opinion, it must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). In remanding this matter, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran’s assertions. Neither the Veteran’s credibility nor any lack thereof should be presumed in this remand. The matter is REMANDED for the following action: 1. Obtain all VA treatment records dated from September 2020 to the Present. 2. Thereafter, obtain a new medical opinion from an appropriate physician regarding the Veteran’s hypertension. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran’s medical history as to hypertension and diabetes, to include their onset, progression and severity of any symptoms. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). The clinician should provide an opinion, with supporting rationale, as to the following: Direct Service Connection (a) Whether the Veteran’s hypertension at least as likely as not (1) had its onset in service, (2) manifested within one year after his discharge, (3) was noted during service with continuity of the same symptomatology since service, or (4) is otherwise related to an in-service injury, event, or disease to include herbicide agent exposure. Consider the Veteran’s report that he has had hypertension since service and, to the extent that this is incongruous or otherwise not supported by the medical record, explain. Secondary Service Connection (b) Whether the Veteran’s hypertension is at least as likely as not (1) proximately due to service-connected diabetes mellitus, or (2) aggravated beyond its natural progression by service-connected diabetes mellitus. Provide a rationale that deals with causation and aggravation as independent concepts. If aggravation is found, the clinician should identify, to the extent possible, the baseline level of disability prior to aggravation. Explain. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): An adequate medical opinion may not be predicated solely on the absence of literature supporting causation or aggravation without discussing those facts specific to this Veteran. NOTE (3): Reliance on the absence of medical literature supporting nexus without discussing the specific facts of the case renders an opinion inadequate. 3. Ensure that the VA medical opinions obtained include a complete rationale for the conclusions reached. The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. M. Pesin 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.