Citation Nr: 21029943 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 14-31 014 DATE: May 17, 2021 REMANDED Service connection for hearing loss. Service connection for tinnitus. Service connection for hypertension. Service connection for residuals of a cerebral vascular accident (CVA). REASONS FOR REMAND The Veteran served on active duty from August 1967 to March 1970; from November 1978 to November 1979; and from January to April 1991. He also served in the U.S. Army Reserves, including a period of active duty for training (ACDUTRA) from February to July1983. The case is on appeal from a March 2011 rating decision. In October 2017, the Veteran testified at a Board hearing. In a June 2018 decision, the Board reopened and remanded the claims for additional development. In March 2020, the Board remanded the claims for additional development. 1. Service connection for hearing loss. 2. Service connection for tinnitus. The Veteran is seeking service connection for hearing loss and tinnitus. He contends that he has hearing loss and tinnitus that are related to his exposure to loud noise primarily from working in helicopters and working as a "tunnel rat" during combat service in the Republic of Vietnam. The Veteran underwent VA examination in April 2014. However, the results concerning the Veteran's current hearing loss were not considered valid. Concerning tinnitus, the examiner noted that the Veteran had mild hearing loss of 30 decibels at 4000 Hz in April 1991 but that it was less likely than not that the Veteran's tinnitus was related to service as he reported it onset as occurring ten years prior. Pursuant to the Board's remand March 2020, an opinion was obtained later that month. The examiner provided a negative etiology opinion concerning hearing loss. She obtained the results of in-service audiograms from the Joint Hearing Loss and Auditory System Injury Registry (JHASIR) and explained that the Veteran had normal hearing sensitivity years after separation from active duty, with no permanent significant threshold shifts having occurred during his active duty periods. In this case, the Board finds that the March 2020 opinion is not entirely sufficient to decide the claim. First, the examiner based her opinion on the Veteran having normal hearing sensitivity years after separation from active duty. However, it is unclear how she reached this conclusion as post service testing results are absent from the record. In addition, the opinion does not address the mild hearing loss of 30 decibels at 4000 Hz in April 1991 identified by examiner who provided the April 2014 opinion. Accordingly, a new examination and opinion are warranted on remand. The intertwined claim of service connection for tinnitus is also remanded. 3. Service connection for hypertension. The Veteran is seeking service connection for hypertension. He contends that his hypertension is related to his combat service. He also contends that his hypertension is secondary to his service-connected PTSD and/or type 2 diabetes mellitus. In addition, the Board found that whether the Veteran's hypertension is related to his presumed exposure to herbicide agents including Agent Orange was raised by the record. The Veteran underwent a VA examination in May 2014. The examiner provided a negative etiology opinion concerning whether the Veteran's hypertension was caused by his service-connected PTSD. She explained that "while stress from multiple sources may lead to a temporary rise in blood pressure, it does not usually in and of itself lead to a clinical diagnosis of hypertension." Pursuant to the Board's March 2020 remand, additional opinions were obtained later that month. The examiner provided negative etiology opinions with regard to direct service connection and secondary causation. She explained that the Veteran's hypertension was likely caused by combination of risk factors. The examiner also provided a negative etiology opinion concerning whether the Veteran's service-connected type 2 diabetes mellitus aggravated his hypertension. She explained that diabetes does not permanently aggravate hypertension unless there is also a diagnosis of renal disease. In this case, the Board finds that the opinions of records are not entirely sufficient to decide the claim. In this regard, the examiner did not address whether the Veteran's hypertension was aggravated by his service-connected PTSD. Accordingly, there was not substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); see D'Aries v. Peake, 22 Vet. App. 97, 104-05 (2008). In addition, in finding that the Veteran's hypertension was not aggravated by his service-connected type 2 diabetes in the absence of diagnosed renal disease, the examiner failed to consider September 2018 and October 2020 notations in the Veteran's VA treatment records indicating that the Veteran may have kidney disease. Accordingly, a new examination and addendum opinion are warranted on remand. 4. Service connection for residuals of a CVA. The Veteran is seeking service connection for residuals of a CVA. He contends that hypertension caused his CVA. He also contends that his CVA is secondary to his service-connected gunshot wound residuals. The claim of service connection for residuals of a CVA must be remanded as there was not substantial compliance with the Board's March 2020 remand directives. Specifically, the Board directed that a new examination and etiology opinions addressing direct service connection and secondary service connection be obtained. Although the examiner provided etiology opinions concerning hypertension, she did not provide etiology opinions addressing residuals of a CVA. As such, there was not substantial compliance with the remand directives, and remand is needed to ensure compliance. See Stegall, 11 Vet. App. at 271; see D'Aries, 22 Vet. App. at 104-05. In light of the remand, updated VA treatment records should be obtained. The matters are REMANDED for the following action: 1. Obtain VA treatment records since May 2020. 2. Schedule the Veteran for a VA examination (or telehealth interview, record review, etc., if an in-person examination is not feasible) by a qualified medical professional for an opinion to determine the nature and etiology of the Veteran's hearing loss and tinnitus. The entire claims file should be reviewed by the examiner. The examiner should first determine whether the Veteran has hearing impairment for VA purposes. It should be explained why any testing cannot be completed and the medical significance of such. The examiner should then provide an opinion as to whether it is at least as likely as not that any hearing loss and/or tinnitus had its onset during service or within one year of separation, or is otherwise related to an in-service injury, event, or disease, including noise exposure during combat service. The examiner should address the mild hearing loss of 30 decibels at 4000 Hz in April 1991. 3. Also, schedule the Veteran for a VA examination (or telehealth interview, record review, etc., if an in-person examination is not feasible) by a qualified medical professional for an opinion to determine the nature and etiology of the Veteran's hypertension. The entire claims file should be reviewed by the examiner. The examiner should then answer the following questions: Is it at least as likely as not (50 percent or greater) that the Veteran's hypertension is related to an in-service injury, event, or disease, including the Veteran's combat service and/or elevated blood pressure readings in STRs? Is it at least as likely as not (50 percent or greater) that the Veteran's hypertension is related to presumed in-service exposure to herbicides such as Agent Orange? Consideration should be given to the National Academy of Sciences (NAS) Institute of Medicine (IOM)'s Veterans and Agent Orange Update 2018, which moved hypertension to the category of "sufficient" evidence of an association from its previous classification in the "limited or suggestive" category? Is it at least as likely as not (50 percent or greater) that the Veteran's hypertension is caused or aggravated by is service-connected PTSD? Is it at least as likely as not (50 percent or greater) that the Veteran's hypertension is caused or aggravated by his service-connected type 2 diabetes mellitus? The examiner should consider September 2018 and October 2020 notations in the Veteran's VA treatment records indicating that the Veteran may have chronic kidney disease. The term "aggravation" means any increase in severity beyond the natural progression of the disease. A detailed rationale supporting the examiner's opinion must be provided. 4. Also, schedule the Veteran for a VA examination (or telehealth interview, record review, etc., if an in-person examination is not feasible) by a qualified medical professional for an opinion to determine the nature and etiology of residuals of the Veteran's CVA. The entire claims file should be reviewed by the examiner. The examiner should then answer the following questions: Is it at least as likely as not (50 percent or greater) that residuals of the Veteran's CVA are caused or aggravated by his service-connected gunshot wound residuals? The examiner should consider the June 2013 opinion from the Veteran's chiropractor indicating that there is a relationship between the Veteran's service-connected gunshot wound residuals and his CVA. If it determined that the Veteran's hypertension was related to or incurred in service, to include exposure to herbicide agents or that the Veteran's hypertension is caused or aggravated by his service-connected PTSD and/or his service-connected type 2 diabetes mellitus, the examiner should also provide an opinion as to whether it is at least as likely as not (50 percent or greater) that residuals of the Veteran's CVA are caused or aggravated by his hypertension. The term "aggravation" means any increase in severity beyond the natural progression of the disease. A detailed rationale supporting the examiner's opinion must be provided. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Gray, 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.