Citation Nr: 21032882 Decision Date: 05/28/21 Archive Date: 05/28/21 DOCKET NO. 15-04 064A DATE: May 28, 2021 REMANDED Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1980 to June 1988. The Veteran died in May 2011 while the above claim was pending. His surviving spouse, the Appellant, was properly substituted as the claimant. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office. In March 2018, the Appellant testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the evidentiary claims file. In February 2020, the Board reopened and remanded this matter to the agency of original jurisdiction (AOJ) for additional development, to include a VA examination. The VA opinion was to address the Veteran's documented, in-service elevated blood pressure readings, and whether hypertension was directly related to service and/or whether it was caused or aggravated by the Veteran's service-connected psychiatric disability. A VA opinion from a VA nurse practitioner was obtained in August 2020. The examiner found no evidence of hypertension or significantly elevated blood pressure readings during active service. Hypertension was determined to have been less likely than not to incurred in or caused by an injury, event, or illness during service, including elevated blood pressure readings. Further, regarding secondary service connection, the examiner opined that the Veteran's service-connected psychiatric disability was less likely than not to cause or exacerbate his hypertension. As rationale, the examiner noted that a December 1988 VA examination indicated mild situational depression and not any severe posttraumatic stress disorder (PTSD) or major psychiatric disorder, that would likely cause or exacerbate hypertension. The examiner explained that any worsening of the Veteran's psychiatric status was immaterial because the core question was whether the Veteran's service either directly or indirectly caused hypertension, and the December 1988 VA examination indicated it was unlikely. The Board notes that while the August 2020 examiner stated that there was no significantly elevated blood pressure reading, review of the Veteran's service treatment records (STRs) show five readings where his diastolic pressure was recorded at 90 or above. See STRs, at September 3, 1982; June 14, 1983; May 7, 1985; August 9, 1985; August 13, 1985. The examiner did not discuss or otherwise explain with specific reference to the Veteran's in-service blood pressure readings why these readings would not be considered significant. Moreover, regarding secondary service connection, the August 2020 examiner appeared to formulate an opinion based exclusively on a December 1988 VA examination that indicated mild situational depression, rather than an evaluation of the entire record. Specifically, service connection for PTSD with depression was granted at the 70 percent rate due to symptoms that caused an occupational and social impairment with deficiencies in most areas, which the examiner failed to consider because it did not represent the Veteran's psychiatric impairment closer to the period of active service. See May 2020 Rating Decision. However, secondary service connection may be established for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (a); Allen v. Brown, 7 Vet. App. 439 (1995). Under these circumstances, the Board finds that another remand is required. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that where remand instructions are not followed, the Board errs as a matter of law when it fails to ensure compliance). The matters are REMANDED for the following action: 1. The agency of original jurisdiction (AOJ) should obtain a medical opinion, preferably from a cardiologist or appropriate specialist in the area of cardiology, regarding the nature and etiology of the Veteran's hypertension. The examiner must review the entire claims file and a copy of this REMAND order before rendering the opinion and include a notation that a record review was performed. The examiner should opine on the following: (a.) whether it is at least as likely as not (i.e., a probability of 50 percent or greater) that the Veteran's hypertension is etiologically related to the Veteran's active duty service. The examiner should consider and address in the opinion the elevated blood pressure readings documented in the Veteran's STRs, to include 118/92, 120/90, 142/92, 140/90, and 140/94, 146/86, and 144/78. See e.g., STR, at September 3, 1982; June 14, 1983; May 7, 1985; August 9, 1985; August 13, 1985; August 19, 1986; September 25, 1986. (b.) Whether it is as least as likely as not (50 percent or greater probability) that the Veteran's hypertension was caused by his service-connected PTSD with depression. (c.) Whether it is as least as likely as not (50 percent or greater probability) that the Veteran's hypertension was aggravated (i.e. any worsening beyond the normal progression of that disease) by his service-connected PTSD with depression. (d.) A complete rationale is requested for all opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, he/she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation (i.e., because the limits of medical knowledge had been exhausted or because further information to assist in making the determination is needed). 2. After completion of the above and any additional development deemed necessary, the issues on appeal should be reviewed with consideration of all applicable laws and regulations. If any benefit sought remains denied, the Appellant and her representative should be furnished a Supplemental Statement of the Case and afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Gipson, 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.