Citation Nr: 21011331 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 15-27 114 DATE: March 1, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to service connected disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1974 to June 1978, which included service during the Vietnam Era. He passed away in February 2017. The Appellant is his surviving spouse and has been granted substitution. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2014 decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2018 and April 2020, the Board remanded the matter for further development, to include obtaining addendum VA medical opinions. As will be discussed below, another remand is warranted for compliance with remand orders. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In April 2020, the Board remanded the claim for new VA opinions because the prior September 2019 VA examiner acknowledged that stress was a risk factor for developing hypertension but did not reconcile the Veteran’s contention that the stress from his service-connected disabilities caused his hypertension. Further, the Board noted that the examiner did not provide any rationale for the aggravation opinion and did not provide an opinion on direct service connection. As such, the Board remanded the claim for new VA opinions on direct and secondary service connection, to include aggravation. In a May 2020 VA opinion and October 2020 addendum, a VA examiner provided medical opinions on direct and secondary service connection theories. For direct service connection, the examiner opined that the Veteran’s hypertension was less likely than not incurred in or caused by his service because medical records are silent for documentation of hypertension in service or within one year after separation. For secondary service connection, the examiner provided negative nexus opinions on the relationship between the Veteran’s hypertension and his service-connected depression, pansinusitis, lumbar back disability, gastroesophageal reflux disease (GERD), tinnitus, asthma, and deviated septum to include aggravation. As rationale, the examiner individually stated that medical records and medical literature does not support a causal relationship between hypertension and any service-connected disability. The examiner further opined that the Veteran’s hypertension was not proximately due to or the result of pain from any of his service-connected disabilities because although pain is associated with an elevation of blood pressure, such elevation occurs during the time of increased pain then decreases after the pain is reduced. As such, the increase cannot be considered a constant rise enough to result in hypertension. When VA undertakes to provide an examination in a service connection claim, it must ensure that the examination and opinion are adequate for decision-making purposes. See 38 C.F.R. § 3.159 (c)(4); see also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In the May 2020 opinion and addendum inadequate because the examiner relied on the absence of evidence in service treatment records in formulating the direct service connection opinion. See Buchannan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Further, for secondary service connection the examiner failed to follow April 2020 remand directives that instructed the examiner to consider relevant lay evidence. Although the May 2020 examiner provided negative nexus opinions on the relationship between hypertension and any service-connected disability, to include aggravation and pain symptoms, the examiner did not reconcile the Veteran’s lay reports that stress from his service-connected disabilities caused his hypertension. For these reasons, a remand is necessary for new medical opinions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion from an appropriate medical professional regarding the nature and etiology of the Veteran’s hypertension. After reviewing the record, the examiner should: (a) Opine as to whether it is at least as likely as not (50 percent probability or greater) the Veteran’s hypertension was caused by or otherwise related to his active duty service and explain why. (b) If the Veteran’s hypertension was not caused by or otherwise related to his active duty service, opine as to whether it is at least as likely as not (50 percent probability or greater) proximately due to or aggravated beyond its natural progression by his service-connected depression, pansinusitis, lumbar back disability, GERD, tinnitus, asthma, and/or deviated septum to include the medications prescribed for these conditions, and explain why. The examiner is reminded that an opinion must address both causation and aggravation. In rendering an opinion, the examiner should consider the relevant service treatment records, to include a July 1976 Chronological Record of Medical Care noting an elevated blood pressure reading of 120/90 mm Hg during the Veteran’s active duty service. In rendering an opinion, the examiner should consider the relevant medical evidence of record, to include a December 1979 S.C.P.M.G. Clinic Progress Record noting a blood pressure reading of 122/90 mm Hg a year and a half following separation from active duty service; a March 2013 VA Mental Health Note from Dr. C.S. opining the Veteran’s hypertension was more likely than not caused by his anxiety disorder; an August 2013 letter from Dr. B.S.C. opining his hypertension was more likely than not related to his anxiety; and generally, the post-separation medical evidence of record documenting elevated blood pressure readings and changes in the medication(s) prescribed. In rendering an opinion, the examiner should consider the arguments raised and medical literature cited in an August 2018 Written Brief Presentation and March 2020 Written Brief Presentation from the Appellant’s representative. In rendering an opinion, the examiner should consider the relevant lay evidence of record, to include the Veteran’s lay statements prior to his passing, to include his (1) statements during the September 2014 VA examination that the symptoms of his hypertension onset during service, and (2) contentions that stress from his service-connected disabilities caused his hypertension. 2. Readjudicate the issue on appeal. If any benefit sought is not granted, then the Veteran and his representative should be furnished with a Supplemental Statement of the Case and afforded an opportunity to respond before the record is returned to the Board for further review. Jenna Brant Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Amanda Baker, 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.