Citation Nr: 21011205 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 18-00 862 DATE: March 1, 2021 REMANDED Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1998 to July 2002. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2017 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). This matter was before the Board in January 2019, the Board denied entitlement to service connection for hypertension. The Veteran appealed the Board’s January 2019 decision to the United States Court of Appeals for Veterans Claims (Court), which in a January 2020 order, granted the parties’ joint motion for partial remand (JMPR), vacating the Board’s January 2019 decision and remanding the case for compliance with the terms of the joint motion. The Veteran’s claim was remanded by the Board in September 2020 in accordance with the JMPR instructions. In accordance with the September 2020 Board remand, the Veteran was afforded a VA examination in December 2020. Entitlement to service connection for hypertension is remanded. The Veteran asserts entitlement to service connection for hypertension. Specifically, the Veteran contends that he had elevated blood pressure during service. See December 2020 VA Examination Report. By way of history, the Veteran was denied entitlement to service connection for hypertension in a January 2019 Board decision. The Veteran appealed the Board’s decision to the Court, which issued a joint motion for partial remand in January 2020. According to the Court, the Board erred by not providing an adequate statement of reasons and bases explaining whether a VA examination is warranted following the Board’s reopening of the Veteran’s hypertension claim. Thus, pursuant to the terms of the parties’ January 2020 JMR, the Board remanded the Veteran’s claim in September 2020 to afford the Veteran a VA examination. In accordance with the September 2020 Board remand directives, the Veteran was afforded a VA examination in December 2020. The VA examiner noted a diagnosis of hypertension in 2017. The Veteran reported a hypertension onset in 2010-2011 after a routine examination by his non-VA provider. The Veteran’s hypertension requires continuous medication. The Veteran’s three current blood pressure readings were 160/105, 170/114, and 160/102. The VA examiner reported the Veteran’s hypertension impacts his ability to work, including experiencing headaches, nosebleeds, and lightheadedness. Following the examination, the VA examiner opined that the Veteran’s hypertension is less likely than not incurred in or caused by service. In support of this opinion, the VA examiner reasoned that, although the Veteran’s entrance examination blood pressure reading was elevated, it was not, in itself, a diagnosis of hypertension and there is no diagnosis before, during, or one year after his discharge from service. Furthermore, the Veteran himself admitted that he received a hypertension diagnosis in 2010 or 2011. A review of the Veteran’s service treatment records (STRs) shows a blood pressure reading of 138/76 at entrance into service. See November 1997 STR. The Veteran denied experiencing high or low blood pressure. Id. A March 1999 STR shows a blood pressure reading of 142/94. A July 1998 dental STR shows a blood pressure reading of 142/76. A June 200 dental STR shows a blood pressure reading of 120/90. A May 2001 dental STR shows a blood pressure reading of 152/84. The Veteran did not undergo a separation examination. An April 2002 STR shows that the Veteran’s medical history was reviewed, and he was physically qualified for separation. The Board finds that the September 2020 VA examination is inadequate for adjudication purposes. The September 2020 VA examiner noted the Veteran’s blood pressure reading at entrance during service. However, the VA examiner did not account for the multiple elevated blood pressure readings throughout service. Accordingly, an addendum opinion is necessary. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Furthermore, the Veteran reported being diagnosed with hypertension in 2010-2011 by his non-VA provider. Review of the record shows that no attempt has been made to obtain the Veteran’s private treatment records for this time period. Thus, an attempt should be made to associate private treatment records dated from 2010, the date the Veteran reported he was diagnosed with hypertension, to the record. If the Veteran does not respond to the request for private records, that should be noted in the file. The matters are REMANDED for the following action: 1. Ask the Veteran to provide the appropriate release so that private medical records may be obtained for the period since 2010. If no records are available or forthcoming, that should be indicated in the claims file. 2. Then refer the claims file to a qualified examiner for an addendum opinion. The entire claims file should be made available to the examiner. No additional examination is necessary, unless the examiner determines otherwise. (a.) Following a review of the claims file the examiner should opine as to whether it is as least as likely as not (50 percent or greater probability) that the Veteran’s hypertension had its onset in service, or is otherwise related to service. In addressing this question please consider the Veteran’s blood pressure readings in service. 3. Then, after taking any additional development deemed necessary, readjudicate the claim and issue a Supplemental Statement of the Case, as appropriate. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. C. Slaughter, 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.