Citation Nr: 21023182 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 15-33 403 DATE: April 20, 2021 REMANDED Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from November 1981 to January 1985. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an October 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Albuquerque, New Mexico. These matters were previously before the Board in August 2020, at which time they were remanded for respective VA examinations. Entitlement to service connection for hypertension is remanded. Though the Board regrets the additional delay, remand is required for an adequate VA opinion. Where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran was provided with a VA examination in January 2021. The examiner determined that it was less likely than not that the Veteran’s hypertension was related to her active duty service. The examiner noted that the Veteran was not diagnosed with hypertension until several years after service and that the June 2010 medical treatment record noted that the Veteran’s hypertension diagnosis was a “new diagnosis.” The examiner noted that there was no diagnosis of hypertension in service when she was discharged at 31 years old. The examiner also noted that the Veteran had other risk factors indicative for hypertension such as a high sodium diet, advanced age, and inactivity. The examiner then determined that the Veteran’s hypertension was not aggravated beyond its natural progression by her service-connected PTSD, MDD, or sleep apnea. The examiner emphasized that the Veteran was successfully controlling her hypertension through the use of one medication which indicated that her condition was not aggravated beyond its natural progression. The examiner noted that the Veteran’s sleep apnea was not diagnosed until nine years after her hypertension diagnosis and as the Veteran was still controlling her hypertension through one medication, the condition was clearly not aggravated. The examiner also noted that on review of blood pressure management guidelines, management of PTSD and MDD were not listed as contributing factors. The Board finds the secondary service connection opinion is inadequate because the incorrect standard was presented to the examiner. The examiner was asked in the examination to determine whether the Veteran’s hypertension was aggravated beyond its natural progression by her service-connected sleep apnea, MDD, or PTSD. The secondary service connection standard asks, however, whether the Veteran’s hypertension was proximately caused or aggravated by her service-connected conditions. The correct standard is any increase in disability; therefore, the examiner utilized a higher standard for aggravation than that set out in the regulations for aggravation of a nonservice-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board points out that aggravation under secondary service connection is distinguishable from the specific standard for aggravation of a pre-existing condition. 38 C.F.R. § 3.306. As such, remand is required for an adequate VA opinion. The matters are REMANDED for the following action: 1. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 2. Contact the appropriate VA Medical Centers and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified, and this should be documented for the record. Required notice must be provided to the Veteran and his or her representative. 3. After any additional records are associated with the claims file, schedule the Veteran for a VA examination to determine the current nature and etiology of any diagnosed hypertension. The claims file must be made available to the examiner, and the examiner must specify in the examination report that these records have been reviewed. a) The examiner is asked to opine as to whether it is as least as likely as not (50 percent probability or greater probability) that any diagnosed hypertension had its onset in service or is otherwise the result of an incident in service. b) The examiner must also opine whether any diagnosed hypertension is at least as likely as not (50 percent or greater probability) proximately due to or the result of (i.e. was aggravated by) the Veteran's service-connected a) sleep apnea and/or b) PTSD and MDD. The examiner should consider all evidence, including lay statements, medical records, and other medical opinions of record. Any opinions offered should be accompanied by a clear rationale consistent with the evidence of record. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. The examiner is reminded that “at least as likely as not" does not mean "within the realm of medical possibility", but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 4. After the above development has been completed, the Agency of Jurisdiction (AOJ) should readjudicate the remaining issue on appeal. Saudiee Brown Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board AK 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.