Citation Nr: 23057729 Decision Date: 10/24/23 Archive Date: 10/24/23 DOCKET NO. 20-12 057 DATE: October 24, 2023 ORDER Entitlement to service connection for hypertension, diagnosed as hypertensive vascular disease (hypertension and isolated systolic hypertension), is granted. REMANDED Entitlement to service connection for a right shoulder radiculopathy, to include as secondary to service-connected cervical spine disability, is remanded. FINDING OF FACT The most probative and persuasive evidence reflects that the Veteran's hypertension is the result of the Veteran's service. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension have been met. 38 U.S.C. § 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 4.104, Diagnostic Code 7101. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1982 to June 1992, to include service in the Persian Gulf. This matter comes on appeal before the Board of Veterans' Appeals (Board) from an October 2017 rating decision by the Department of Veteran's Affairs (VA). The Veteran expressed disagreement with these determination in a timely NOD filed in November 2017, and the present appeal ensued. The Veteran declined a Board Hearing. The Board notes that in a January 2020 rating decision, the RO granted service connection as to all the appealed claims, except the claims of service connection for hypertension and service connection for right shoulder radiculopathy. As such, those other issues have been granted in full by the AOJ and are no longer before the Board for consideration. Thus, the only claims on appeal before the Board pertain to the denial of service connection for hypertension and service connection for right shoulder radiculopathy. 38 C.F.R. §§ 19.22, 19.52(b). 1. Entitlement to service connection for hypertension, diagnosed as hypertensive vascular disease (hypertension and isolated systolic hypertension). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When all the evidence is assembled, VA is responsible for determining whether the evidence persuasively favors the claim or is in approximate balance, that is, nearly equal, with the veteran prevailing in either event. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776, 781-782 (Fed. Cir. 2021). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-449 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, and a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372, 1376-1377 (Fed. Cir. 2007). The Board notes that it has reviewed all of the evidence in the record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim being decided. Analysis The Veteran contends that he is entitled to service connection for his hypertension condition. Initially, the Board notes that the Veteran currently suffers from hypertension as diagnosed in a September 2019 VA hypertension examination. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). Next, as noted in the September 2019 VA hypertension examination, service treatment records show that, between the years 1987 and 1992, the Veteran had several blood pressure readings in which his diastolic blood pressure was predominantly 90 mm Hg or higher. Specifically, between the years 1987 and 1992, the Veteran had diastolic blood pressure readings of 100 mm Hg, 90 mm Hg, 94 mm Hg and 96 mm Hg. Thus, the VA examiner noted that the Veteran suffered from hypertension at least since 1982, that is, while he was in service. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). In light of the above, the first two elements necessary to establish direct service connection have been demonstrated, and the crux of the Veteran's case is whether the most probative evidence reflects that his current hypertension disability is related to service. The Board finds that the evidence of record shows that the Veteran's hypertension is related to service. As previously noted, the September 2019 VA hypertension examination noted that the Veteran suffered from hypertension at least since 1982, that is, while he was in service. The Board further notes that since hypertension is a chronic disease, the Veteran's credible statements of continuity of symptoms can also serve as a substitute for medical nexus. Thus, the Board finds that the most probative and persuasive evidence reflects that the Veteran's hypertension had its onset during the Veteran's service. As such, all the elements necessary to establish service connection for this condition have been demonstrated, and service connection for this disability is warranted. 38 U.S.C. §§ 1110, 1131, 5107 (b); 38 C.F.R. §§ 3.102, 3.303; Lynch v. McDonough, 21 F.4th 776, 781-782 (Fed. Cir. 2021). REASONS FOR REMAND 1. Entitlement to service connection for a right shoulder radiculopathy, to include as secondary to service-connected cervical spine disability. The Veteran contends that he is entitled to service connection for his right shoulder radiculopathy condition as secondary to his service-connected cervical spine disability. The Board notes that the Veteran is service-connected for cervical spine retrolisthesis and spondylosis with multiple degenerative disk disease (DDD), intervertebral disc syndrome (IVDS), facet hypertrophy, and arthropathy (previously rated as degenerative disk C1-C3) as secondary to service connection for lumbar spine degenerative arthritis with intervertebral disc syndrome (IVDS), scoliosis, retrolisthesis and spondylosis (claimed as lumbar scoliosis, degenerative disc and arthritis, spondylosis, stenosis, lumbar spine). See January 2020 rating decision of record. VA treatment records show that the Veteran reported symptoms of right shoulder pain since, at least, 2012. In 2012, he reported right shoulder and neck pain and was diagnosed with chronic shoulder joint pain. Also, in 2014, he was diagnosed with cervicalgia and joint pain localized in shoulder. Finally, VA treatment records for the year 2012 note that the Veteran informed that he would visit a private specialist to obtain a diagnosis regarding his right shoulder condition. See VA treatment records, Madigan Army Medical Center. Private treatment records show that in 2008 the Veteran complained about pain across shoulders and tension in his shoulders. Also, a radiological cervical report noted that it was "[n]egative for recent fracture or gross osteopathology as visualized. A loss of the normal cervical shaped lordotic curve is noted. Narrowed disc spaces between C4/5 is noted." See private treatment records, Pain Treatment and Wellness Center, PC. In September 2019, the Veteran was afforded a VA neck cervical spine conditions examination. The VA examiner opined that the claimed condition was less likely than not (less than 50 percent probability) proximately due to or the result of a Veteran's service-connected condition. The VA examiner noted that the Veteran showed no radiculopathy symptoms and therefore there was no objective evidence to support a diagnosis of radiculopathy which could be associated with a service- connected disability. In June 2018, the Veteran was also afforded a private medical examination. The Veteran reported aching pain and a pins and needles sensation involving the right shoulder, and weakness in his right arm. The private examiner noted symptoms of pain radiating to the tip of the Veteran's right shoulder and the lateral aspect of his right arm but not his elbow, mild crepitus of the right shoulder, and mild impingement of the right shoulder. Finally, the private examiner concluded that the Veteran's cervical spondylosis had caused his pain in the right shoulder. The Board finds the September 2019 VA neck cervical spine conditions examination inadequate for the following reasons. First, the examination failed to consider the Veteran's VA and private treatment records, and the June 2018 private medical examination, and thus ignored and failed to take into consideration the Veteran's history of symptoms and diagnoses related to his right shoulder. Second, the examination did not provide a rationale and opinion as to the relationship, if any, between the Veteran's right shoulder symptoms and diagnoses, and his service-connected cervical spine disability. The Board also finds the June 2018 private medical examination inadequate because it did not take into consideration the Veteran's history of symptoms and diagnoses related to his right shoulder and did not provide a rationale as to the relationship, if any, between the Veteran's right shoulder symptoms and diagnoses and his service-connected cervical spine disability. Thus, the Board concludes that an addendum opinion regarding the etiology of the Veteran's right shoulder condition is necessary. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c); Stefl v. Nicholson, 21 Vet. App. 120, 124-125 (2007). The Board notes that VA treatment records for the year 2012 show that the Veteran informed that he would visit a private specialist to obtain a diagnosis regarding his condition right shoulder condition. See VA treatment records, Madigan Army Medical Center. This indicates that the Veteran received some kind of treatment for his right shoulder condition; however, records have not been requested or obtained by VA. As such, efforts should be made to ensure that all VA treatment or private treatment records are associated with the claims file. The Veteran is asked to submit any records in his possession regarding the alleged right shoulder condition. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159 (c); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. The Agency of Original Jurisdiction should ensure that all VA treatment records dated from service separation in 1992 to the present have been associated with the claims file. 2. Contact the Veteran and request that he identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who have treated him for his right shoulder symptoms particularly between 1992 and the present. The Veteran should be requested to sign any necessary authorization for release of medical records to VA, and appropriate steps should be made to obtain any identified records. 3. The AOJ must transfer the Veteran's electronic file to an appropriate VA clinician for the purpose of obtaining a medical opinion regarding the relationship between the Veteran's service-connected cervical spine retrolisthesis and spondylosis with multiple degenerative disk disease (DDD), intervertebral disc syndrome (IVDS), facet hypertrophy, and arthropathy (previously rated as degenerative disk C1-C3) and the Veteran's right upper extremity radiculopathy symptoms. After review of the file, the VA clinician is asked to provide an opinion regarding whether the Veteran has a diagnosis of right upper extremity radiculopathy, if any, and whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) proximately due to or the result of, or aggravated by, the Veteran's service-connected cervical spine retrolisthesis and spondylosis with multiple degenerative disk disease (DDD), intervertebral disc syndrome (IVDS), facet hypertrophy, and arthropathy (previously rated as degenerative disk C1-C3), to include the medical treatment for such. *In addressing the above, the VA clinician must discuss all diagnoses, if any, pertaining to the Veteran's right upper extremity radiculopathy symptoms and all radiological studies related to those diagnoses. All requested opinions must be accompanied by a full rationale citing to accepted medical principles and evidence specific to the Veteran's case. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Aquino Ramos, Carlos M. 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.