Citation Nr: 21027599 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 16-03 897A DATE: May 6, 2021 REMANDED The issue of service connection for bilateral hearing loss is remanded. The issue of service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served in the U.S. Army from October 1971 to October 1991. 1. The issue of service connection for bilateral hearing loss is remanded. VA treatment records indicate that there are several audiogram results in VA's CPRS program which are not in the Veteran's file. Remand is necessary because the complete audiogram results must be associated with the record. Remand is also necessary to obtain a new VA audiological examination and medical opinion. An October 2019 remand directed the RO to obtain an examination and opinion. The December 2019 VA examination indicates that the test results were not reliable. An April 1991 service treatment record (STR) and post-service VA treatment records indicate a history of cerumen build-up affecting audiology test results, and many VA audiological test results are noted to be unreliable. A July 2018 VA treatment record states that cerumen management is warranted prior to a hearing check. Therefore, on remand, cerumen management should be undertaken and then a VA audiology examination should be conducted. 2. The issue of service connection for hypertension is remanded. A March 2011 VA treatment record states that the Veteran's hypertension was followed by an outside physician at Blanchfield Army Community Hospital. Remand is necessary to attempt to obtain these treatment records. Remand is also necessary to obtain an addendum medical opinion. The October 2019 Board remand directed the RO to obtain an examination and opinion. However, the December 2019 opinions obtained pursuant to the October 2019 Board remand are inadequate. Specifically, the examiner indicated that hypertension was not caused by service because the Veteran did not have hypertension at his July 1991 physical examination for service separation. An in-service diagnosis is not required for a grant of service connection. See 38 C.F.R. § 3.303(d). Additionally, the examiner stated that the Veteran was not diagnosed with hypertension until September 2010. A December 1992 VA examination report states that the Veteran had a diagnosis of possible borderline hypertension. The examiner did not discuss this piece of evidence and it appears the examiner only reviewed blood pressure readings from March 1989, July 1991, and September 2010, despite many more blood pressure readings in the record. Furthermore, the October 2019 Board remand directed the RO to obtain medical opinions regarding whether hypertension was caused or aggravated by the medication the Veteran took to treat his service-connected musculoskeletal disorders. The examiner provided general information about hypertension from medical literature, including that the use of NSAIDs increases blood pressure. She also stated that the Veteran was taking NSAIDs and concluded, without rationale, that hypertension was not caused or aggravated by the medication. This examination report is inadequate, and remand is necessary. The matters are REMANDED for the following action: 1. Associate with the record any VA clinical documentation not already of record pertaining to the treatment of the Veteran for bilateral hearing loss and hypertension, including audiogram results from October 2011, May 2012, January 2013, February 2016, and September 2018, which are not currently in the Veteran's file. 2. Advise the Veteran that he may submit any additional medical and non-medical evidence relating to his claimed bilateral hearing loss and hypertension that is not already in VA's possession. Specifically request authorization to obtain any treatment records from Blanchfield Army Community Hospital. 3. After associating the above-requested records with the file or documenting their unavailability in the record, schedule the Veteran for a VA examination to obtain an opinion as to the nature and etiology of bilateral hearing loss. To the extent possible, cerumen management should be undertaken prior to attempting to obtain a VA audiological examination. All indicated tests and studies should be accomplished and the findings reported in detail. All relevant medical records must be made available to the examiner for review of pertinent documents. The examination report should specifically state that such a review was conducted. The examiner must provide a comprehensive explanation for all opinions provided. The examiner should address the following: (a.) Whether bilateral sensorineural hearing loss was caused by in service noise exposure. (b.) Whether there was a threshold shift in hearing while in service. In providing the opinions, the examiner should expressly address: (1) the Veteran's report at the December 2019 VA examination that he first noticed hearing loss in the 1980s; (2) April 1991 STR stating that the Veteran had a history of cerumen build-up which affected his hearing; (3) in-service audiometric test results which indicated fluctuating results, with a high of 25 decibels in both ears at 500 Hertz in May 1989; and (4) December 1992 VA examination where the Veteran reported fluctuating hearing loss which began 2 years prior, while he was in service, when a mortar round exploded near him. The examiner is advised that VA has conceded the Veteran's in-service exposure to hazardous noise as service connection for tinnitus has been in effect since the date after service separation. The examiner is also advised that an opinion based solely on normal hearing at service separation is inadequate. 4. After associating the above-requested records with the file or documenting their unavailability in the record, request that a PHYSICIAN (other than the Family Nurse Practitioner who conducted the December 2019 VA hypertension examination) provide an addendum medical opinion to assist in determining the nature and etiology of the hypertension (another examination of the Veteran is not required). If the VA examiner determines that an additional examination of the Veteran is necessary to provide reliable opinions as to causation and aggravation, such examination should be scheduled; however, the Veteran should not be required to report for another examination as a matter of course, if it is not found to be necessary. All relevant medical records must be made available to the examiner for review of pertinent documents. The examination report should specifically state that such a review was conducted. The examiner must provide a comprehensive explanation for all opinions provided. The examiner should address the following: (a.) Whether hypertension was caused by any in service event, injury, disease, or disorder, or in any way originated during service. The examiner should expressly address: (1) whether any of the Veteran's in-service blood pressure readings or (2) the December 1992 VA examination diagnosis of possible borderline hypertension, indicated hypertension, borderline hypertension, or the beginning of what would eventually become hypertension, especially in light of the revision of the definition of hypertension by the medical community in recent years. (b.) Whether hypertension was caused by any service-connected disability, including medication taken to treat any service connected disability, such as NSAIDS. (c.) Whether hypertension was aggravated (worsened in severity beyond a normal progression) by any service-connected disability, including medication taken to treat any service connected disability, such as NSAIDS. If it is determined that the hypertension is worsened beyond its natural progression by a service-connected disability, discuss whether the baseline level of severity of the hypertension is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the hypertension. If the examiner is unable to establish a baseline for hypertension prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. Service connection is currently in effect for lumbar muscular strain with left and right lower extremity radiculopathy involving the sciatic nerves, tinnitus, left foot metatarsalgia, gastroesophageal reflux disease (GERD), and left foot plantar warts. L.M. YASUI Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. E. Miller, 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.