Citation Nr: 21012296 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 09-00 177 DATE: March 4, 2021 REMANDED 1. Entitlement to service connection for hypertension is remanded. 2. Entitlement to service connection for heart disease, to include coronary artery disease (CAD), cardiomyopathy, and congestive heart failure (CHF), is remanded. 3. Entitlement to service connection for residuals of a cerebrovascular accident (CVA) is remanded. 4. Entitlement to service connection for peripheral artery disease (PAD) is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from March 1972 to June 1975. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a June 2007 rating decision which, in relevant part, denied service connection for hypertension, heart disease, residuals of a CVA, and bilateral infrapopliteal disease. In February 2012, a Travel Board hearing was held before the undersigned; a transcript is in the Veteran’s record. These matters were remanded for additional development in April 2012, August 2015, and July 2017. In December 2018, the Board denied the claims. The Veteran appealed that decision to the U.S. Court of Appeals for Veterans Claims (CAVC), resulting in a February 2020 Joint Motion for Remand (JMR) by the parties. A March 2020 CAVC Order remanded the matters for compliance with the JMR instructions. In October 2020, the Board remanded the matters for additional development. 1. Entitlement to service connection for hypertension In the February 2020 JMR, the parties agreed that the August 2017 VA medical opinion regarding the etiology of the Veteran’s hypertension (on which the Board’s December 2018 denial was based in part) “does not substantially comply with the terms of the Board’s July 2017 remand. Specifically, the parties agreed that the pertinent question in this case is not whether [the Veteran] was diagnosed with hypertension as defined by the Rating Schedule during service or within the first post-separation year, as the August 2017 VA examiner repeatedly references, but whether the single elevated blood pressure reading documented in service, coupled with the post-service reading of 145/90 on the May 1976 VA examination within one year of separation, were initial manifestations of hypertension.” The parties agreed that on remand, “the Board shall obtain a new VA medical opinion, or seek clarification of the August 2017 VA medical opinion, to address these issues.” Accordingly, in October 2020, the Board remanded the matters for additional development, including specifically for an adequate advisory medical opinion addressing the medical question stated by the parties in the February 2020 JMR. An addendum advisory medical opinion was obtained in October 2020. The August 2017 physician examiner reviewed the record and provided a negative nexus (to service) opinion; he opined that the likely etiology of the Veteran’s hypertension is essential hypertension. However, the opinion provided is not fully responsive to the Board’s remand directive; specifically, the rationale did not address whether the single elevated blood pressure reading documented in service, coupled with the May 1976 post-service (within one year of separation) reading of 145/90 were initial manifestations of hypertension, as required to resolve with the remaining medical question that was agreed upon by the parties in the February 2020 JMR. [The Board notes that the opinion identified a distinction/importance in blood pressure cuff size depending on a patient’s body mass index (BMI), but does not address the significance of such (i.e. does an improper cuff size lead to an inaccurate higher or lower reading, and why).] Accordingly, the opinion is not fully responsive to the Board’s remand directives, and corrective action (development for a more complete medical advisory opinion) is necessary. See Stegall v. West, 22 Vet. App. 268, 271 (1998). Finally, the Board notes that the Veteran’s representative before CAVC (not his current representative before the Board) contended that, pursuant to Sullivan v. McDonald, 815 F.3d 786, 792 (Fed. Cir. 2016), VA failed to satisfy its duty to assist by failing to remand the appeal to obtain records of treatment from the Philadelphia VA outpatient clinic (VAOPC) from 1975 and 1976. See March 2020 statement (citing to the May 1976 VA examination report which notes VA treatment since 1975 for headaches). The Board observes that the file contains a November 2011 informal memorandum that Philadelphia VAMC outpatient treatment records are “up to date and printed through” November 14, 2011 (suggesting all available records were obtained). Nevertheless, as there is an indication that additional records of VA treatment may be outstanding, and as VA treatment records are constructively of record, they must be sought on remand. 2., 3., 4. Entitlement to service connection for heart disease, residuals of a CVA, and PAD In the February 2020 JMR, the parties agreed that the claims seeking service connection for heart disease, residuals of a CVA, and PAD are inextricably intertwined with the claim seeking service connection for hypertension, and that the additional development required on remand for the hypertension claim may impact these claims. The matters are REMANDED for the following: 1. Arrange for exhaustive development to secure for the record complete updated (any not already associated with the record) VA treatment records, including specifically all treatment and examination reports from 1975 and 1976 from the Philadelphia VAOPC/VAMC. The search should encompass all storage facilities where such records may have been retired. If the records cannot be located because they are irretrievably lost or destroyed (or did not exist), so certify, describing the scope of the search, and the Veteran should be so notified. 2. Thereafter, arranger for the Veteran’s record to be forwarded to the August 2017 VA hypertension examiner for review and an addendum advisory medical opinion regarding the likely etiology of his hypertension. [If that provider is unavailable or unable to provide the opinion sought, the record should be forwarded to an appropriate clinician (e.g., internist or cardiologist) for review and the opinion sought. [If further examination is necessary, such should be arranged.] On review of the complete record (including this remand and any records received pursuant to the development ordered above), the examiner should: (a) Identify the likely etiology for the Veteran’s hypertension. Specifically, is it at least as likely as not (a 50% or better probability) that such is etiologically related to his service/events therein? - The rationale for the opinion must specifically address whether the single elevated blood pressure reading documented in service, coupled with the post-service reading of 145/90 on the May 1976 VA examination (within one year following separation) were initial manifestations of hypertension. - The rationale should also provide a brief discussion (beyond what was provided in the October 2020 opinion) of the significance of blood pressure cuff size and BMI when taking a blood pressure reading (Does an improper cuff size lead to an inaccurate higher or lower reading, and if so, why?). (b) If the Veteran’s hypertension is determined to be unrelated to his service, identify the etiology that is considered to be more likely (and explain why that is so). The examiner should explain the rationale for all opinions, citing to supporting factual data, and medical principles as deemed appropriate. 3. Thereafter, review the record and arrange for any further development necessary with respect to the claims of service connection for heart disease, residuals of a CVA, and PAD (e.g., a nexus opinion regarding secondary service connection, if hypertension is determined to be service-connected). GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Dupont, 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.