Citation Nr: 18145013 Decision Date: 10/25/18 Archive Date: 10/25/18 DOCKET NO. 10-11 246A DATE: October 25, 2018 REMANDED Entitlement to service connection for gout, to include as due to toxic herbicide exposure and type 2 diabetes mellitus, is remanded. Entitlement to service connection for hypertension, to include as due to toxic herbicide exposure, is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1965 to December 1966, which included combat experience and service in the Republic of Vietnam. This matter comes before the Board of Veteran’s Appeals (Board) on appeal of a January 2009 rating decision by the Department of Veterans Affairs (VA). The Veteran attended a May 2017 videoconference hearing before the undersigned judge. A hearing transcript is of record. The issues on appeal were previously remanded by the Board in August 2017 and have now been returned for further action. The Board acknowledges that the Veteran’s hearing loss claim remains in a separate appeal stream. Additionally, the Veteran has disagreed with a previous denial of a total disability rating based on individual unemployability (TDIU). However, the Board declines to take jurisdiction over the claims at this time. 1. Entitlement to service connection for gout, to include as due to toxic herbicide exposure and type 2 diabetes mellitus, is remanded. In August 2017, the Board remanded the Veteran’s claim for service connection for gout in order for VA to provide an opinion on whether the Veteran’s gout is related to service, to include his toxic herbicide exposure and type 2 diabetes mellitus. The examiner was also asked to opine on any potential worsening of the gout that may have been caused by his diabetes. In a November 2017 addendum opinion, a VA examiner opined against a direct service connection linkage between gout and military service, citing the lack of any conditions related to gout in the Veteran’s service treatment records. Also, the examiner determined that the Veteran’s gout was less likely than not caused or aggravated by the Veteran’s type 2 diabetes mellitus. The examiner stated that a review of the medical literature supports diabetes as a modifiable risk factor for gout, but that there was no evidence showing this risk factor as a contributing factor to his gout in this instance. The examiner also listed hypertension as a risk factor for gout. As noted by the Veteran’s representative, the examiner cited diabetes as a modifiable risk factor for gout, but does not explain why it is not a risk factor for gout in this instance. Additionally, the examiner did not address whether the Veteran’s gout was worsened beyond its natural progression by his type 2 diabetes mellitus. Finally, with the examiner citing hypertension as a risk factor for gout, this relationship requires further explanation. Consequently, the Board concludes that there has not been substantial compliance with its previous remand. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Another VA medical opinion is necessary to answer the questions originally posed regarding direct service connection, toxic herbicide exposure, and type 2 diabetes mellitus. The examiner will also be asked to expand on their comment listing hypertension as a risk factor for gout as well as their succinct direct service connection opinion. The Board acknowledges the representative’s argument that the examiner failed to explain the etiology of the Veteran’s gout if his diabetes is unrelated to the disorder. However, in the context of a VA disability claim, the examiner is not required to determine the exact etiology of a disorder if the examiner is able to otherwise rule out a connection to military service. 2. Entitlement to service connection for hypertension, to include as due to toxic herbicide exposure, is remanded. In August 2017, the Board remanded the Veteran’s claim for service connection for hypertension in order for VA to provide an opinion on whether the Veteran’s hypertension is related to service, to include his toxic herbicide exposure. The Board noted that the National Academy of Sciences Institute of Medicine 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). In a November 2017 addendum opinion, a VA examiner opined against a linkage between hypertension and the Veteran’s toxic herbicide exposure, citing the fact that hypertension is not a presumptive disease that can be attributed to toxic herbicide exposure. The examiner also opined against a linkage between hypertension and military service, citing the fact that it did not manifest within one year of service. As noted by the Veteran’s representative, the examiner did not mention the National Academy of Sciences study or any other medical literature pertaining to the potential connection between hypertension and toxic herbicide exposure. Additionally, other than noting that the Veteran’s hypertension did not manifest within the presumptive period, the examiner did not provide an explanation for their opinion regarding direct service connection. Consequently, the Board concludes that there has not been substantial compliance with its previous remand. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Another VA medical opinion is necessary to answer the questions originally posed regarding direct service connection and toxic herbicide exposure. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s gout is (1) at least as likely as not related to military service and (2) at least as likely as not related to toxic herbicide exposure. The examiner should also address whether the Veteran’s gout is at least as likely as not related to, proximately due to, or aggravated beyond its natural progression by (1) type 2 diabetes mellitus and (2) hypertension. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s hypertension is (1) at least as likely as not related to military service and (2) at least as likely as not related to toxic herbicide exposure. When answering the question regarding toxic herbicide exposure, the examiner should remark on the National Academy of Sciences study cited above. B.T. KNOPE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Borman, Associate Counsel