Citation Nr: 18141320 Decision Date: 10/10/18 Archive Date: 10/10/18 DOCKET NO. 18-26 978 DATE: October 10, 2018 REMANDED Entitlement to service connection for sleep apnea, to include as due to herbicide exposure, is remanded. Entitlement to service connection for hypertension, to include as due to herbicide exposure, is remanded. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from April 1968 to November 1969, to include service in the Republic of Vietnam, as well as subsequent service in the National Guard and Reserves. This case comes before the Board of Veterans’ Appeals (Board) on appeal from December 2014 and June 2015 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. REASONS FOR REMAND The Board finds that additional development is required before the claims on appeal are decided. Service Connection Sleep Apnea The Veteran asserts that he has sleep apnea that is related to his active service. The Board notes that the Veteran has a diagnosis of sleep apnea. Moreover, the Veteran provided a statement from his wife, who stated that she had observed the Veteran’s sleep impairments since 1991. To date, no VA medical opinion has been obtained on the Veteran’s claimed sleep apnea. Therefore, the Board finds the Veteran should be afforded a VA examination to determine the nature and etiology of his sleep apnea. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Hypertension In December 2014, the Veteran was afforded a VA examination. The examiner indicated that the Veteran had hypertension since the mid 1970’s and opined that the Veteran’s hypertension was not likely related to his military service, to include his herbicide exposure therein. In reaching this conclusion, the examiner relied on the fact that the Veteran’s November 1969 separation examination was silent for a diagnosis of hypertension. Further, in reaching her negative nexus opinion, the examiner relied solely on the fact that hypertension was not on the VA’s presumptive list. In October 2017, the Veteran was afforded another examination. The examiner opined that it was less likely than not that the Veteran’s hypertension was related to service. However, the examiner did not address the Veteran’s conceded exposure to herbicides. The Board finds the December 2014 and October 2017 VA medical opinions inadequate for adjudication purposes. In this regard, the Board notes that the December 2014 VA examiner relied solely on the absence of complaints in the Veteran’s separation examination as her basis for a negative nexus opinion. Moreover, the December 2014 VA examiner did not address whether the Veteran’s hypertension could be related to herbicide exposure, notwithstanding the fact that it is not on the VA’s presumptive list. Further, the October 2017 VA examiner did not address the Veteran’s herbicide exposure in his opinion. As noted above, the Veteran served in the United States Army from April 1968 to November 1969. During this time, the Veteran served in the Republic of Vietnam, and is thus presumed to have been exposed to herbicides. Although hypertension is not listed as a disease associated with herbicide exposure under 38 C.F.R. § 3.309(e), the National Academy of Sciences Institute of Medicine (NAS) has concluded that there is “limited or suggestive evidence of an association” between herbicide exposure and hypertension. See 77 Fed. Reg. 47924, 47926-927 (Aug. 10, 2012). Given the foregoing, the Board finds an additional examination and opinion is required to determine the nature and etiology of the Veteran’s hypertension, to include whether the Veteran’s hypertension is related to his conceded herbicide exposure during service in the Republic of Vietnam. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The matters are REMANDED for the following action: 1. Identify and obtain any pertinent, outstanding VA and private treatment records and associate them with the claims file. 2. Then, schedule the Veteran for a VA examination to determine the nature and etiology of his sleep apnea. The claims file must be made available to, and reviewed by the examiner. Any indicated studies should be performed. Based on the examination results and the review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that sleep apnea had its onset during active service, or is otherwise etiologically related to active service, to include the Veteran’s presumed herbicide exposure (notwithstanding the fact that it may not be a presumed association). The examiner should specifically consider whether the Veteran history supports in-service onset and continuity of symptoms since service. The examiner should further consider the February 2015 lay statement from his wife, who reports noticing snoring since they were together in 1991. A complete rationale for the medical opinion is required. The examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). If an opinion cannot be expressed without resort to speculation, the examiner should so indicate and discuss 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. 3. Schedule the Veteran for a VA examination by an examiner with appropriate expertise to determine the nature and etiology of the Veteran’s hypertension. The claims file must be made available to, and reviewed by the examiner. Any indicated studies should be performed. Based on the examination results and a review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that hypertension (i) had its onset during service or (ii) manifested to a compensable degree within one year after active service, or (iii) is otherwise etiologically related to his active service, to include the Veteran’s conceded herbicide exposure (notwithstanding the fact that it may not be a presumed association). The examiner should specifically consider whether the Veteran’s history supports in-service onset and continuity of symptoms since service. In rendering the opinion, the examiner should consider the National Academy of Sciences excerpt indicating a limited or suggestive association between herbicide exposure and hypertension. A complete rationale for the medical opinion is required. The examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). If an opinion cannot be expressed without resort to speculation, the examiner should so indicate and discuss 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. 4. Ensure that the VA medical opinions obtained include a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two.   5. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. O’Donnell, Associate Counsel