Citation Nr: 21022405 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 17-66 157 DATE: April 15, 2021 REMANDED Service connection for hypertension (claimed as high blood pressure) is remanded. Service connection for residuals of a stroke is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1985 to February 1990. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. The Veteran testified at a Board hearing before the undersigned Veterans Law Judge in September 2020. A transcript of the hearing is of record. Hypertension The Veteran contends that his hypertension is related to his service-connected back disability. Specifically, the Veteran testified that the different medications he takes for his back pain cause him to have elevated blood pressure readings. The Veteran also testified that he has elevated blood pressure when he experiences exacerbations of his back pain. Although there is evidence in the record with respect to the connection between the Veteran’s back pain and hypertension, both positive and negative, the Board finds the evidence inadequate for adjudicative purposes, requiring further remand. An August 2013 VA treatment note from the Veteran’s treating primary care VA physician stated that the Veteran’s episodes of elevated blood pressure were more likely than not associated with his acute lower back pain. That VA physician also submitted an October 2013 letter stating that the Veteran’s hypertension was “generally under good control but noted to be elevated with episodes of lower back pain.” The Board finds that the treating physician’s conclusory statements with no rationale in support of the opinion are inadequate to support service connection. An August 2013 VA treatment note from a treating VA neurologist suggests that the Veteran’s high blood pressure is aggravated by his chronic low back and neck pain. The Board finds the opinion inadequate as the neurologist failed to establish the baseline of the Veteran’s hypertension or the degree to which it was aggravated by back pain. The Board also finds the negative VA opinions in the record inadequate. A November 2013 VHA opinion concluded that there was no way of knowing if the Veteran’s lumbar strain contributed to his hypertension without resorting to mere speculation. The July 2014 and March 2016 VA medical opinions concluded that the Veteran’s hypertension was not caused by his low back pain, but failed to address whether the Veteran’s hypertension was aggravated by his service-connected back disability. The VA opinions are thus incomplete and inadequate for adjudicative purposes. Under 38 U.S.C. § 5109(a), VA may obtain an advisory medical opinion from an independent medical expert from outside the Department based upon the medical complexity or controversy of a particular case. Here, given the competing medical opinions, the lack of an adequate opinion, and the medical complexity of whether the Veteran’s hypertension is related to his service-connected back condition, the Board finds that remand is warranted to obtain an additional opinion from a specialist outside the Department. Stroke Residuals The Veteran contends that his stroke was caused by his hypertension, and medical evidence in the record supports his claim. The resolution of the hypertension claim will thus impact this issue, requiring it to also be remanded. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (stating that issues are inextricable intertwined when a decision on one issue would have a significant impact on another issue). The matters are REMANDED for the following action: 1. Notify the Veteran and his representative that VA is requesting an advisory medical opinion pursuant to 38 U.S.C. § 5109 regarding the issue of entitlement to service connection for hypertension. 2. Then, pursuant to 38 U.S.C. § 5109, forward the Veteran’s claims file to a non-VA independent medical expert. The entire claims file, including a copy of this Remand, must be made available to and must be reviewed by the expert. The expert should then address the following: (a.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran’s hypertension is proximately due to the Veteran’s service-connected back disability, to include the medications he takes for back pain. (b.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran’s hypertension was aggravated (worsened beyond natural progression) by the Veteran’s service connected back condition. In providing responses to parts (a) and (b), the expert should provide separate opinions with distinct rationales. In providing responses to parts (a) and (b), the expert should specifically consider and discuss the Veteran’s reports that his medication for back pain resulted in elevated blood pressure and that exacerbations of back pain caused elevated blood pressure, including when the Veteran did not seek treatment for the back pain. The examiner should also consider and discuss the opinions offered by the Veteran’s treating VA physician and neurologist. A fully articulated medical rationale for each opinion expressed must be set forth in the medical report. The examiner should discuss the particulars of the Veteran’s medical history and the relevant medical science as applicable to this case, including any relevant medical literature. If the expert cannot provide an opinion without resorting to speculation, he or she should explain why an opinion cannot be provided (e.g. lack of sufficient information/evidence, the limits of medical knowledge, etc.) Following receipt of the requested opinion, furnish a copy of the opinion to the Veteran and his representative and allow them an adequate time to submit any response. S.C. KREMBS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Snyder, 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.