Citation Nr: 22017110 Decision Date: 03/24/22 Archive Date: 03/24/22 DOCKET NO. 18-04 537 DATE: March 24, 2022 REMANDED Entitlement to a disability rating in excess of 10 percent for hypertension is remanded. Entitlement to service connection for heart disease to include hypertensive heart disease, coronary artery disease, and acute, subacute, or old myocardial infarction; and to include as secondary to service-connected hypertension, is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1985 to February 1988 and from September 2002 to September 2003, with additional service in Army Reserve. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 2016 rating decision of a Department of Veterans Affairs (VA) regional office (RO) that denied an increased rating for hypertension. In May 2019, the Board remanded the increased rating claim for further development. In May 2020, the Board denied the claim of an increased rating for hypertension. The Veteran appealed the denial to the United States Court of Appeals for Veterans Claims (the Court). In August 2021, the Court granted a joint motion for remand vacating the Board decision and remanded the matter for the Board to address whether the medical evidence reasonably raised a claim of service connection for a heart condition. In November 2021, the Board took jurisdiction of the issue of entitlement to service connection for a heart disability, to include as secondary to service-connected hypertension, pursuant to the holding of the Court in Bailey v. Wilkie, 33 Vet. App. 188 (2021). The Board remanded both issues for further development. In the November 2021 remand, the Board directed the RO to obtain a medical opinion on whether the heart disability is related to hypertension. In a December 2021 VA medical opinion, the clinician did not address whether the heart disease was aggravated by hypertension. Therefore, the RO did not comply with the directives of the November 2021 Board remand. Stegall v. West, 11 Vet. App. 268 (1998). Moreover, the clinician did not address a July 2021 private treatment record showing a diagnosis of hypertensive heart disease. In light of the above, a VA examination and a new medical opinion are necessary. The Veteran was last examined in March 2020. Given the passage of time and possible worsening due to the diagnosis of hypertensive heart disease, a new VA examination addressing hypertension is warranted. The RO should obtain any additional treatment records from the VA Texas Valley Coastal Bend Health Care System from December 2021 to the present. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all treatment for hypertension and heart disease. Obtain any identified records. Obtain the Veteran's VA treatment records from the VA Texas Valley Coastal Bend Health Care System from December 2021 to the present. 2. After the development in 1 is completed, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of hypertension and nature and etiology of the heart disease. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's hypertension under the rating criteria. The examiner must opine on whether it is at least as likely as not that the Veteran has hypertensive heart disease. For any other heart disease other hypertensive heart disease, the clinician must opine on whether it is at least as likely as not that the heart disease is related to an in-service injury, event, or disease during active duty from February 1985 to February 1988. The clinician must opine on whether it is at least as likely as not that heart disease (1) began during active duty from February 1985 to February 1988, or (2) manifested within one year after discharge from service in February 1988. For any other heart disease other hypertensive heart disease, the clinician must opine on whether it is at least as likely as not that the heart disease is related to an in-service injury, event, or disease during active duty from September 2002 to September 2003. The clinician must opine on whether it is at least as likely as not that heart disease (1) began during active duty from September 2002 to September 2003, or (2) manifested within one year after discharge from service in September 2003. For any other heart disease other hypertensive heart disease, the clinician must opine on whether it is at least as likely as not that the heart disease was (1) caused by or (2) aggravated by hypertension. If the clinician finds that the heart disease was aggravated by hypertension, then the medical professional should quantify the degree of aggravation. 3. After development above has been completed, the RO should readjudicate the claims. If any benefit is not granted, the Veteran must be furnished with a supplemental statement of the case, with a copy to his representative, and afforded an opportunity to respond. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Cherry, 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.