Citation Nr: 21041686 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 11-01 212 DATE: July 9, 2021 REMANDED Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1986 to October 1989 with subsequent service in the Reserves. This matter returns to the Board of Veterans' Appeals (Board) on appeal from a December 2009 rating decision issued by the Department of Veterans' Affairs (VA) Regional Office (RO). The Board notes that this matter was previously remanded in a October 2020 Board decision for an examination to determine whether the Veteran's hypertension disability was caused by or aggravated during service and whether the Veteran was entitled to secondary service connection for her hypertension disability. The Board also requested that the examiner provide an opinion specifically addressing whether the Veteran's service-connected conditions caused or aggravated her obesity, and if so, whether obesity is a substantial factor in her diagnosis of hypertension. A review of the record since the October 2020 remand does not reflect that the developmental actions were consistent with all of the directives of that remand, particularly with respect to the examiner specifying the legal standard applied in each opinion offered. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary, and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. Accordingly, remand is required to obtain an adequate medical opinion that complies with the Board remand directives. Entitlement to service connection for hypertension is remanded. The Veteran contends that her hypertension began during service, or in the alternative, that her service-connected conditions caused or aggravated her sedentary lifestyle which was a substantial factor leading to hypertension. She asserts that her hypertension began during service with high blood pressure readings. The Veteran's service treatment records are silent for any complaints, reports, or symptoms of hypertension. The Veteran's treatment records reflect a diagnosis of hypertension many years after separation from service. Additionally, the Board notes that the Veteran's treatment provider opined that her degenerative spinal diseases "affected her status in terms of obesity and general physical fitness, " which in part, prompted the Board's October 2020 remand to obtain an opinion on whether the Veteran's service-connected conditions caused or aggravated obesity and whether obesity is a substantial factor in the Veteran's diagnosis of hypertension. The Veteran was afforded an examination in November 2020 to evaluate her hypertension disability. The examiner stated that he found no evidence in the Veteran's STRs that she ever had an elevated blood pressure or diagnosis of hypertension while in service. The examiner reasoned that all of the Veteran's blood pressure readings were within normal limits in service and further stated that the Veteran was diagnosed with hypertension more than 10 years after service, so the condition is not remotely related to service. The examiner also noted that the Veteran is not considered obese by medical standards, but is considered overweight. The examiner further stated that the Veteran's service-connected disabilities did not cause or aggravate her weight gain. The examiner explained that gaining weight in and of itself could lead to obesity which would aggravate or cause hypertension, sleep apnea, hyperlipidemia, and chronic pain and further stated that smoking aggravates these conditions. Additionally, the examiner stated that the Veteran's complaint of being overweight is a self-limiting condition and would resolve with proper exercise, diet regimen, and quitting smoking. Moreover, the examiner stated that the Veteran's current medical conditions do not prevent her from performing the tasks listed that would help the Veteran lose weight. The examiner noted that if the Veteran performed these tasks consistently, it is very likely that she would significantly improve or eliminate the conditions noted. The examiner provided links to two medical articles to support his opinion. Although the examiner offered rationale for the views expressed, there was no legal standard provided for the degree of probability with respect to service connection on a direct or secondary basis. The examiner did not use the correct legal standard of "at least as likely as not" in the medical opinions offered. Therefore, a remand for clarification is necessary. Given that the examiner did not include a legal standard for the opinions offered, the Board finds that the November 2020 opinions inadequate. Thus, remand is warranted. The matter is REMANDED for the following action: 1. Obtain an addendum medical opinion from the examiner who provided the November 2020 opinion, or if unavailable, a medical professional with appropriate expertise regarding the Veteran's claim for hypertension. The examiner should review this remand decision and the Veteran's claims file in its entirety. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. The examiner shall issue an addendum opinion addressing the following: a. Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's hypertension was caused by or incurred during service. b. Whether it is at least as likely as not (50 percent or greater probability) any of the Veteran's service connected disabilities caused or aggravated the Veteran's obesity, and if so, whether it is at least as likely as not (50 percent or greater probability) obesity was a substantial factor in causing or aggravating (increase in severity beyond its natural progression) hypertension, and would hypertension not have occurred or been aggravated, but for the obesity caused by the service connected disorder(s). The examiner must consider the February 2019 statement from Dr. M.S. which noted the Veteran's degenerative spinal diseases "affected her status in terms of obesity and general physical fitness." The examiner must use the appropriate legal standard ("at least as likely as not") when rendering his or her opinion. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. The examiner is advised that causation and aggravation are separate questions, and therefore both theories must be addressed in the opinion. The examiner is to address the Veteran's statements that her hypertension began during service and review her service treatment records. The examiner must provide a complete rationale for any opinion expressed, based on the examiner's clinical and medical expertise; established medical principles; and references to the evidence of record, as appropriate. If any opinion cannot be expressed without resort to speculation, ensure that the examiner so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Dorsey-Kwansa, 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.