Citation Nr: 21016034 Decision Date: 03/19/21 Archive Date: 03/19/21 DOCKET NO. 15-37 508 DATE: March 19, 2021 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for sleep apnea is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1977 to July 1990 and from October 1990 to May 1997. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an April 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). These issues were remanded by the Board in September 2018 and July 2020 for further development. 1. Entitlement to service connection for hypertension is remanded. The July 2020 remand directives instructed that the Veteran be provided a new examination and that nexus opinions be given for direct and secondary service connection. The Veteran was afforded a VA hypertension examination in December 2020; unfortunately, the nexus opinions are inadequate. Regarding the negative opinions for secondary service connection, the examiner failed to provide adequate rationales. The rationale for the proximate causation prong of secondary service connection was identical to the rationale given for direct service connection and did not clearly address whether the current hypertension is proximately caused by or aggravated by any of the Veteran’s service-connected disabilities. An adequate medical examination “must support its conclusions with an analysis that the Board can consider and weigh against contrary opinions” and must “provide sufficient detail for the Board to make a fully informed evaluation of whether service connection is warranted.” Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The lack of adequate medical opinions in this case makes it impossible for the Board to make an informed determination as to whether service connection for hypertension is warranted on a direct or secondary basis. See Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012). Accordingly, addendum opinions are required. The Board also notes that in ‘Section II-Medical History’ of the previous July 2019 VA examination report, the examiner included a date of onset for hypertension of ‘1993,’ which the Board bote would have been during the Veteran’s active duty service. However, in the medical opinion section, the examiner opined hypertension did not onset in service. She unequivocally stated there is no evidence of hypertension or elevated blood pressure during service; multiple blood pressure readings taken during service show normal blood pressure. In the current July 2020 VA examination report, the most recent VA examiner also determined that hypertension did not onset in service and indicated there are no records of a diagnosis in service. The examiner did not, however, attempt to reconcile the date of onset provided in the July 2019 VA examination report. On remand, the examiner is asked to attempt to reconcile this finding and clarify whether there is any indication on review of the service treatment records that hypertension onset in service, including in 1993 specifically. 2. Entitlement to service connection for sleep apnea is remanded. The July 2020 remand directives instructed that the Veteran be provided a new examination and that opinions be given for direct and secondary service connection. The opinion for direct service connection was to specifically address the lay evidence of record. The Veteran was afforded a VA sleep apnea examination in December 2020; unfortunately, the nexus opinions are inadequate. When providing a negative opinion for direct service connection, the examiner failed to adequately address the lay statements of record. The provided rationale reflects that there is no medical evidence in the Veteran’s service treatment records to support a finding that sleep apnea had its onset during active service and that consideration was given to the lay statements of record. However, the opinion and rationale do not sufficiently explain why the alleged snoring and breathing difficulties in service support the opinion that sleep apnea did not onset in service or is not related to service. When providing negative opinions for secondary service connection, the examiner failed to provide adequate rationales. The rationale for the proximate causation prong of secondary service connection was the identical to the rationale given for direct service connection and did not clearly address whether the current hypertension is proximately caused by or aggravated by any of the Veteran’s service-connected disabilities. The rationale for the aggravation prong of secondary service connection was similarly deficient. Accordingly, addendum opinions are needed. See Stefl, supra; Nieves-Rodriguez, supra; and Monzingo, supra. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician to determine the etiology of the Veteran’s hypertension. The examiner must review the claims file, and a copy of this Remand. Following a review of the record, the examiner should: a) Provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) the current hypertension had its clinical onset during active service or is related to any in service disease, event, or injury. In offering the opinion, the examiner is asked to reconcile, if at all possible, the reported date of onset for the diagnosis of hypertension which was listed in ‘Section II-Medical History’ of the July 2019 VA examination report as ‘1993.’ In other words, is there any plausible basis for finding that hypertension manifested in service, and specifically in 1993? b) Provide an opinion as to whether it is at least as likely as not the current hypertension was proximately caused by a service-connected condition. c) Provide an opinion as to whether it is at least as likely as not any current hypertension was aggravated (i.e., worsened beyond its natural progression) by a service-connected condition. A rationale must be provided for all opinions. 2. Obtain an addendum opinion from an appropriate clinician to determine the etiology of the Veteran’s sleep apnea. The examiner must review the claims file, and a copy of this Remand. Following a review of the record, the examiner should: a) Provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) any current sleep apnea had its clinical onset during active service or is related to any in-service disease, event, or injury. In providing the requested opinion, consider the Veteran’s description of his in-service symptoms as well as his post-service symptoms. He and his wife assert that he snored and had difficulty breathing in service. If there is any medical reason to accept or reject the proposition that the Veteran’s reported symptoms in service and thereafter represented the onset of his current sleep apnea disability, this should be noted. Stated another way, do the lay reports about the Veteran’s symptoms align with how the sleep apnea is known to develop or are they generally inconsistent with medical knowledge or implausible? b) Provide an opinion as to whether it is at least as likely as not the current sleep apnea was proximately caused by a service-connected condition. c) Provide an opinion as to whether it is at least as likely as not any current sleep apnea was aggravated (i.e., worsened beyond its natural progression) by a service-connected condition. A rationale must be provided for all opinions. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Caban, 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.