Citation Nr: 21015512 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 15-10 613A DATE: March 17, 2021 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a heart condition as secondary to hypertension is remanded. Entitlement to service connection for a kidney condition as secondary to hypertension is remanded. Entitlement to service connection for a right eye condition as secondary to hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1978 to October 1984. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision of August 2013 issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Decatur, Georgia. Following the rating decision on appeal, the Veteran timely filed his notice of disagreement (NOD) in October 2013. The RO issued a statement of the case (SOC) in April 2015 and the Veteran’s timely appeal to the Board followed later that month. A hearing was conducted before the Board in April 2018 and a transcript of that hearing is of record. The Board subsequently remanded the Veteran’s case in August 2018 for further development. See August 2018 Board Remand. Following a supplemental statement of the case (SSOC) in May 2019, the Board denied these claims in a decision of August 2019. See August 2019 Board Decision. The Veteran appealed the Board’s August 2019 decision to the Court of Appeals for Veterans Claims (CAVC). The CAVC subsequently vacated and remanded the Board’s decision, finding that the Board had relied on an inadequate VA examination report and had not ensured that its previous August 2018 remand directives were substantially fulfilled. See July 2020 CAVC Decision at 3-6; see also Stegall v. West, 11 Vet. App. 268, 271 (1998) (providing that a remand confers upon the Veteran the right to substantial compliance with remand instructions). Entitlement to service connection for hypertension and associated heart, kidney, and right eye conditions. The Veteran asserts that he has hypertension due to his active-duty service and associated heart, kidney, and right eye conditions secondary to such hypertension. See April 2018 Transcript at 11-12. In its July 2020 decision, the CAVC noted that the Board’s August 2018 remand had directed the RO to obtain VA treatment records prior to September 2005, as well as private treatment records for hypertension. See August 2018 Board Remand at 7-10; see also July 2020 CAVC Decision at 3-5. While the August 2019 Board decision had found that these records were no longer necessary, the CAVC determined that the Board had not adequately explained this finding. See id. at 4 (providing that the Board had not explained why discrepancies between the Veteran’s statements to a VA examiner and his hearing testimony justified the continued absence of pre-September 2005 records); see also id. at 4-5 (finding that the Board’s conclusion that the Veteran had not assisted the RO in obtaining relevant private treatment records was not consistent with the Veteran’s timely submission of the relevant forms, albeit with an error); see also id. at 5 (directing the Board to ensure substantial compliance with its August 2018 remand directives before readjudicating the Veteran’s claims). Additionally, the CAVC found that an April 2019 VA examination report did not adequately explain the reasoning supporting its conclusions and was therefore inadequate to support the Board’s adjudication of the Veteran’s claims. See July 2020 CAVC Decision at 6 (providing that the VA examiner did not explain why a blood pressure reading taken during a report on body fat composition would be “situational” or otherwise unreliable); see also id. (providing that the VA examiner did not explain why the Veteran “must have had new employee physical exams with [blood pressure] checks from 1984 until 2004”); see also id. (directing the Board to remand the Veteran’s claims for an adequate VA examination report before readjudication). These matters are therefore REMANDED for the following action: 1. Obtain any outstanding (not already obtained) VA treatment records dated prior to September 23, 2005, and dated May 2018 to present. If such records cannot be located, document all efforts to obtain them and clearly explain why further attempts to obtain them would be futile. 2. Obtain private treatment records associated with the Veteran’s treatment for hypertension at Grady Memorial Hospital. Provide the Veteran with any forms necessary to authorize the release of such records. If the Veteran timely submits such forms, but the submitted forms contain errors or are otherwise insufficient to provide the necessary authorization, notify the Veteran and explain the action necessary to correct such errors. 3. Provide the Veteran’s claims file to an appropriately-qualified examiner. The examiner shall review the claims file, including a copy of this remand, and provide opinions as to the following questions: (a.) Is it at least as likely as not that the Veteran’s hypertension is due to or aggravated by his active-duty service? (b.) If so, is it at least as likely as not that the Veteran’s heart, kidney, and right eye conditions are due to or aggravated by his hypertension? In providing these opinions, the examiner should clearly address the reasoning and relevant evidence supporting their conclusions, including previous examination reports, the Veteran’s medical treatment records, and credible lay statements from the Veteran. If the examiner concludes that such lay statements are not credible, the examiner should likewise clearly explain the reasoning supporting such a conclusion. If the examiner concludes that medical treatment records would have been made during a given time period, and that the absence of such treatment records therefore supports a conclusion that no condition existed at that time, the examiner shall clearly explain their reasoning for determining that medical records would have been made. If the examiner is unable to provide such opinions without personally examining the Veteran, schedule the Veteran for such an examination. LLOYD CRAMP Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Blore, 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.