Citation Nr: 18147340 Decision Date: 11/06/18 Archive Date: 11/02/18 DOCKET NO. 15-39 973 DATE: November 6, 2018 REMANDED Service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder and/or herbicide agent exposure, is remanded. Service connection for neuropathy of the left lower extremity, to include as secondary to herbicide agent exposure, is remanded. Service connection for neuropathy of the right lower extremity, to include as secondary to herbicide agent exposure, is remanded. REASONS FOR REMAND The Veteran honorably served on active duty from September 1968 to July 1971. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a February 2012 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. The Veteran only perfected his appeal to the Board on the issues of service connection for hypertension and peripheral neuropathy. See October 2015 Veteran’s Appeal to the Board (VA Form 9). Therefore, the issues of increased evaluation for tinnitus and bilateral hearing loss, as well as the issues of service connection for allergies, a skin condition, and poor vision, are not before the Board. 1. Service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD) and/or herbicide agent exposure, is remanded. The Veteran has a current diagnosis of hypertension. See March 2012 General Medicine Note by K.T., M.D. The Veteran has also reported two in-service events, including manifestation of hypertension during service and herbicide agent exposure. See February 2011 Report of General Information (VA Form 21-0820); December 2016 Veteran’s Affidavit. The Veteran has also submitted treatise evidence supporting a relationship between hypertension and PTSD. See December 2016 Veteran’s Treatise Evidence. VA is required to provide examination when there is insufficient medical evidence to decide the claim, but the record otherwise contains competent evidence of a current disability or recurrent symptoms, evidence of an in-service event, and evidence of an indication of a nexus. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010); 38 C.F.R. § 3.159(c)(4)(i). The Veteran has also submitted a hypertension disability benefits questionnaire (DBQ) by a private provider. See December 2016 Hypertension DBQ by S.S., M.D. However, medical treatment notes by this provider are not contained within the record. Because this issue must already be remanded, this additional development should be completed as well. 2. Service connection for neuropathy of the left lower and right lower extremities, to include as secondary to herbicide agent exposure, are remanded. The Veteran has claimed that he has peripheral neuropathy due to herbicide agent exposure. See February 2011 Report of General Information (VA Form 21-0820). Although there is no direct evidence of a diagnosis, the fact that the Veteran has submitted a claim indicates that he believes he at least has some symptoms of peripheral neuropathy (which are observable by a lay person such as the Veteran). Further, the existence of a presumption of service connection for peripheral neuropathy due to exposure to herbicide agents, see 38 C.F.R. §§ 3.307, 3.309, supports a finding that there is an “indication” of a nexus to such exposure, even if the claim cannot be granted under a presumption. See Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed.Cir.1994) (holding that when a veteran is found not to be entitled to a regulatory presumption of service connection for a given disability the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis). VA is required to provide examination when there is insufficient medical evidence to decide the claim, but the record otherwise contains competent evidence of a current disability or recurrent symptoms, evidence of an in-service event, and evidence of an indication of a nexus. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010); 38 C.F.R. § 3.159(c)(4)(i). The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the Veteran’s disabilities. 2. Send a letter to the Veteran requesting that he identify any relevant outstanding private treatment records and any other relevant evidence pertaining to his claim of entitlement to service connection for hypertension and for peripheral neuropathy. He should be invited to submit this evidence himself or to request that VA to obtain it on his behalf. Authorized release forms (VA Form 21-4142) should be provided for this purpose. If the Veteran properly fills out and returns any authorized release forms for private records identified by him, reasonable efforts should be made to obtain such records and associate them with the claims file. At least two such efforts should be made unless it is clear from the private provider’s response to the first request that a second effort would be futile. If attempts to obtain any records identified by the Veteran are not successful, he MUST be notified of this fact and all efforts to obtain them must be documented and associated with the claims file. 3. After completing directives one and two, the AOJ should arrange for a VA examination of the Veteran to determine the nature and likely cause of any hypertension. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s current hypertension was incurred in military service, to include as manifesting in service? The examiner’s opinion MUST address the Veteran’s statement that he was first diagnosed in service and had symptoms he relates to hypertension, including heart pounding, headaches, nosebleeds, dizziness, and fatigue. The examiner’s attention is drawn to the following records (the following is a brief factual background and not intended to be a substitute for your review of the Veteran’s claims folder): *A March 1971 examination reflecting blood pressure of 120/80. *A March 1971 examination reflecting symptoms of nervousness, fatigue, head spinning sensation, and nose bleeds. *A May 1971 examination reflecting symptoms of continuous headaches. (b.) Is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s current hypertension was incurred in military service, to include as a result of herbicide agent exposure? The examiner is advised that exposure to herbicide agents MUST be presumed. (c.) Is it at least as likely as not (defined as a 50% or better probability) that the Veteran’s current lung disability(ies) was proximately caused by OR AGGRAVATED by the Veteran’s service-connected posttraumatic stress disorder? The examiner’s opinion MUST addressed the Veteran’s submitted medical treatise evidence, received December 2016. The examiner is advised that AGGRAVATION is defined as a permanent increase in severity of the disability beyond its natural progression. The examiner is advised that, BY LAW, the particular facts and circumstances of the Veteran’s case (i.e., his particular medical condition and circumstances) must be addressed. Detailed rationale and reasoning for all opinions and conclusions provided is required BY LAW. Providing an opinion without a thorough explanation will delay processing of the claim and may result in a clarification being requested. If it is not possible to provide any of the requested information, the examiner must state whether this is because of a deficiency in the state of general medical knowledge (that is, no one could respond, given medical science and the known facts), a deficiency in the record (that is, additional facts are required), or the examiner (that is, the examiner does not have the required knowledge or training). If the examiner cannot provide answers because further information or diagnostic studies are required, all reasonable steps to obtain this information or diagnostic studies should be exhausted before concluding that the answer cannot be provided. 4. After completing directives one and two, the AOJ should arrange for a VA examination of the Veteran to determine the nature and likely cause of any peripheral neuropathy. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that addresses whether it at least as likely as not (defined as a 50% or better probability) that the Veteran’s claimed peripheral neuropathy was incurred in military service, to include as a result of herbicide agent exposure. The examiner is advised that exposure to herbicide agents MUST be presumed. The examiner is advised that, BY LAW, the particular facts and circumstances of the Veteran’s case (i.e., his particular medical condition and circumstances) must be addressed. Detailed rationale and reasoning for all opinions and conclusions provided is required BY LAW. Providing an opinion without a thorough explanation will delay processing of the claim and may result in a clarification being requested. If it is not possible to provide any of the requested information, the examiner must state whether this is because of a deficiency in the state of general medical knowledge (that is, no one could respond, given medical science and the known facts), a deficiency in the record (that is, additional facts are required), or the examiner (that is, the examiner does not have the required knowledge or training). [CONTINUED ON THE NEXT PAGE]  If the examiner cannot provide answers because further information or diagnostic studies are required, all reasonable steps to obtain this information or diagnostic studies should be exhausted before concluding that the answer cannot be provided. VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Lambert, Associate Counsel