Citation Nr: 22015992 Decision Date: 03/21/22 Archive Date: 03/21/22 DOCKET NO. 18-39 105 DATE: March 21, 2022 ORDER Entitlement to service connection for a disability manifested by numbness in the face is denied. REMANDED Entitlement to an increased initial compensable rating for hypertension is remanded. FINDINGS OF FACT 1. The Veteran's service-connected tension headache presentation already includes the symptom of facial numbness. 2. No functional impairment has been associated with the numbness symptom. CONCLUSION OF LAW The criteria for service connection for a disability manifested by facial numbness have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from August 1999 to December 2003 and from July 2005 to February 2009. The Veteran testified at a video conference hearing before the undersigned Veterans Law Judge in November 2021. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303 (a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). When service connection is established for a secondary disability, the secondary disability shall be considered a part of the original disability. Id. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Following a careful review of the evidence of record, the Board finds the evidence persuasively weighs against the award of service connection for facial numbness separate from the service-connected tension headaches. Specifically, the Board finds that the Veteran's facial numbness is already contemplated by the service-connected tension headaches. At the November 2021 Board hearing, the Veteran testified he first began experiencing what he described as left sided facial numbness around 2012 in tandem with his service-connected headache disorder. He further described experiencing this phenomenon only whenever he also experienced his headaches. There did not appear to be any isolated incidents of complaints of facial numbness apart from the headaches. At the Veteran's April 2019 VA headaches examination the Veteran identified a number of accompanying symptoms, to specifically include sensory changes, such as tingling or numbness. Given the Veteran's testimony of the numbness accompanying his headaches, this is understood to confirm the Veteran's testimony concerning his symptoms presentation. A review of the Veteran's VA outpatient treatment records did not reveal any disability other than headaches that could account for facial numbness. Imaging reports have demonstrated no findings accounting for a facial numbness disorder. No particular functional impairment has been associated with the sensation the Veteran reports. As this record shows the facial numbness complaints began after service; of itself, it is not shown to produce functional impairment, and in any event, it is part of the presentation of the Veteran's service connected headache disability, for which the Veteran is assigned a 50 percent disability evaluation, the evidence persuasively weighs against a finding that the Veteran has a facial numbness disorder separate from the service-connected tension headaches, that was incurred in service. Accordingly, the appeal in this regard is denied. REASONS FOR REMAND The Veteran has claimed that his service connection hypertension is worse that currently reflected by his noncompensable evaluation. At the November 2021 Board hearing, the Veteran indicated that his condition had been worsening and that he was going to his next regular cardiovascular appointment in January 2022. The Veteran was last provided with a VA examination for his hypertension in May 2018, almost four years ago. The Veteran further related that he received all of his care for his hypertension at the VA Medical Center. The claims file only reflects VA outpatient treatment records up to July 2019, several years ago. Although the 2018 VA examination may have been adequate at the time, the contrast with the potential showings of a worsening condition must be reconciled. VA has a duty to assist Veterans to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159. This duty to assist includes providing a thorough and contemporaneous medical examination. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991). In this regard, VA must provide a new examination when a Veteran claims that a disability is worse than when originally rated or when the available evidence is too old to adequately evaluate the current state of the condition. See Olson v. Principi, 3 Vet. App. 480, 482 (1992) (citing Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992)). A potential for worsening symptoms since the 2018 VA examinations has been indicated. As such, it is necessary to obtain new examinations in order to assess the current effects of the Veteran's disabilities. Additionally, in light of the Veteran's contentions, recent VA outpatient treatment records should be obtained and associated with the claims file. The matters are REMANDED for the following action: 1. With any necessary assistance from the Veteran, obtain any outstanding medical evidence dated since the 2019 Statement of the Case, to include VA outpatient treatment referenced at the November 2021 Board hearing. (Continued on the next page) 2. After any additional evidence has been associated with the claims file, the Veteran should be afforded an appropriate examination in order to determine the current severity of his hypertension. The entire claims file should be made available to and be reviewed by the examiner. Any indicated tests and studies should be accomplished. All clinical findings should be reported in detail and correlated to a specific diagnosis. The examiner also should consider the Veteran's reported history. 3. Thereafter, readjudicate the appeal. M. E. KILCOYNE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dodd, Ryan 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.