Citation Nr: 18141547 Decision Date: 10/11/18 Archive Date: 10/10/18 DOCKET NO. 10-08 212A DATE: October 11, 2018 REMANDED Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1963 to October 1967. He died in July 2013. The appellant is his surviving spouse. In July 2013, she filed VA Form 21-0847, Request for Substitution of Claimant Upon Death of Claimant, requesting to be substituted for the Veteran to continue his appeal. In January 2017, the RO determined that she was an eligible substitute and substituted her as the claimant in this appeal. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. In May 2017, the Board remanded the claim for additional development. 1. Entitlement to service connection for hypertension is remanded. Having carefully reviewed the evidence of record, the Board finds that remand is necessary to address matters raised by the appellant’s representative in the recent Informal Hearing Presentation. Her representative argued that the August 2017 VA medical opinion failed to acknowledge National Academy of Sciences (NAS) findings on hypertension. In this regard, the Board notes that hypertension is not one of the presumptive conditions listed in 38 C.F.R. § 3.309(e), and the regulation specifically states that the definition for ischemic heart disease does not include hypertension. Prior to 2006, NAS placed hypertension in the “Inadequate or Insufficient Evidence” category. However, in its Update 2006, NAS elevated hypertension to the “Limited or Suggestive Evidence” category. Update 2012 provides the history of NAS changing the categorization of hypertension beginning in its 2006 Update and subsequent Updates. See 79 Fed. Reg. 20,308 (Apr. 11, 2014). Update 2012 notes that NAS has defined this category of limited or suggestive evidence to mean that the “evidence suggests an association between exposure to herbicides and the outcome, but a firm conclusion is limited because chance, bias, and confounding could not be ruled out with confidence.” Id. at 20,309 Considering the representatives concerns and given the aforementioned NAS Updates, the Board believes that an addendum is necessary to ensure the adequacy of the VA medical opinion in this matter. Accordingly, the matter is REMANDED for the following action: 1. Obtain an addendum from the physician that prepared the August 2017 VA medical opinion. The record, to include a copy of this Remand, must be made available to and be reviewed by the physician. If he is not available, the record should be provided to another appropriate medical professional to render the requested opinion. Following a review of the record, provide an opinion on the following: (a.) Is it at least as likely as not (a 50 percent probability or greater) that the deceased Veteran’s hypertension was related to his active duty military service, to include VA conceded exposure to herbicides? i. Consider and discuss NAS’s Update 2012, which reflects that NAS has placed hypertension in the category of limited or suggestive evidence, which means that the “evidence suggests an association between exposure to herbicides and the outcome, but a firm conclusion is limited because chance, bias, and confounding could not be ruled out with confidence.” ii. The examiner's rationale cannot rely solely on the fact that VA has not included hypertension in the list of presumptive conditions. In other words, the Board needs an opinion as to the likelihood that this Veteran’s hypertension, without regard to the conditions VA recognizes as being due to herbicide agents, is nevertheless at least as likely as not related to his exposure to herbicide agents in service. iii. The examiner is also advised that the sole basis for a negative opinion cannot be the fact that the Veteran’s service treatment records are silent as to any treatment or diagnosis for essential hypertension. iv. Address the Veteran’s theory that hypertension diagnosed after service was initially manifested in service as demonstrated by the elevated blood pressure findings. (b.) Is it at least as likely as not (a 50 percent or greater probability) that hypertension manifested within one year after service? If so, please describe the manifestations. A complete rationale for the medical opinion is required. The physician 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 physician 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. 2. Ensure that the VA medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. 3. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Thomas, Associate Counsel