Citation Nr: 21025184 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 15-22 614 DATE: April 27, 2021 REMANDED Entitlement to service connection for hypertension is remanded REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 1983 to October 2003. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a September 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In January 2019 the Board reopened, and remanded, the Veteran’s claim for entitlement to service connection for hypertension. This case was most recently before the Board in November 2020, when it was remanded to the agency of original jurisdiction (AOJ) for additional development. After taking further action, the AOJ confirmed and continued the prior denial and returned the case to the Board. 1. Entitlement to service connection for hypertension. Although the Board sincerely regrets the additional delay, a remand is necessary to ensure that there is a complete record upon which to decide the Veteran’s claim and to afford him every possible consideration. The Board finds that a remand is necessary in order to attempt to obtain relevant medical records. November 2009 records entitled Service Treatment Records demonstrate the Veteran had hypertension upon a physical examination by an Alabama Department of Corrections provider. It was noted that a letter be sent by the Veteran’s personal doctor related to the Veteran’s hypertension. This suggests the Veteran may have had a private medical care provider at the time and records from such a source could be relevant to the Veteran’s claim. May 2011 VA treatment records indicate the Veteran had hypertension, and was on medication, since 2000. June 2011 VA treatment records demonstrate he was advised that he should contact his primary care provider about his hypertension. September 2011 VA treatment records demonstrate that the Veteran reported that 4-5 years prior he was told he had borderline IOP (intraocular pressure). In May 2015 the Veteran reported to the VA examiner that he was diagnosed with hypertension in 1998 by a civilian provider. He reported that around 2003 he was seen at S. H. hospital and was prescribed hydrochlorothiazide. Records from the treatment identified above are not currently associated with the claims file. This evidence could bear on the outcome of the Veteran’s appeal, as such efforts must be made to procure them. See, e.g., 38 C.F.R. § 3.159(e)(2) (if VA becomes aware of the existence of relevant records before deciding a claim, VA will, among other things, request that the claimant provide a release for the records). The matters are REMANDED for the following action: 1. Ask the Veteran to provide releases for relevant records of treatment related to his hypertension to include a 2009 private medical provider, any non-VA sources that prescribed the Veteran medications related to hypertension, the source that told the Veteran he had IOP 4-5 years prior to June 2011, the source that diagnosed the Veteran with hypertension in 1998, and S.H. hospital around 2003. If he provides the necessary release, assist him in obtaining the records identified, following the procedures set forth in 38 C.F.R. § 3.159. Any new or additional (i.e., non-duplicative) evidence received should be associated with the record. If any of the records sought are not available, the record should be annotated to reflect that fact and the Veteran, and his representative should be notified. 2. Obtain all outstanding VA treatment records and associate them with the claims file. 3. DO NOT SCHEDULE THE FOLLOWING until all the above VA and private records have been obtained to the extent possible. Then, make arrangements to provide the record on appeal to the examiner who previously offered an opinion with respect to the etiology of the Veteran’s hypertension in December 2020. The examiner should be asked to again review the expanded record and prepare a supplemental report that addresses the following questions: (a.) Is it at least as likely as not (i.e., is it 50 percent or more probable) that the Veteran’s hypertension had its onset during, or is otherwise related to service? (b.) Is it at least as likely as not that the Veteran’s hypertension was (i) caused or (ii) aggravated (i.e., worsened beyond natural progression) by his service-connected disabilities? A complete medical rationale for all opinions expressed must be provided. If the December 2020 examiner is no longer employed by VA or is otherwise unable to provide the opinion(s) requested, arrange to obtain the requested information from another qualified examiner. The need for another examination and/or telephonic or video interview of the Veteran is left to the discretion of the examiner(s) selected to offer the requested opinions. 4. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran’s claim should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. R. Costello Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Smith, 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.