Citation Nr: 18148246 Decision Date: 11/08/18 Archive Date: 11/07/18 DOCKET NO. 17-09 172 DATE: November 8, 2018 REMANDED Entitlement to service connection for chronic fatigue syndrome with fibromyalgia and encephalomyelitis, to include as secondary to herbicide exposure and/or posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for hypertension, to include as secondary to herbicide exposure and/or PTSD, is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1963 to March 1967. This appeal comes before the Board of Veterans’ Appeals (Board) from several rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO), Waco, Texas. 1. Entitlement to chronic fatigue syndrome with fibromyalgia and encephalomyelitis, to include as secondary to herbicide exposure and/or PTSD, is remanded. Regarding the claim for service connection for chronic fatigue syndrome, to include as due to his service in the Republic of Vietnam, he has presumed herbicide exposure in service. The Veteran is also service-connected for PTSD. The Veteran's military personnel records confirm that he served in Vietnam during the Vietnam Era (and is therefore presumed to have been exposed to herbicides/Agent Orange during such service). Certain diseases may be service connected on a presumptive basis as due to exposure to herbicides/Agent Orange if manifested in a Veteran who served in the Republic of Vietnam during the Vietnam Era. 38 U.S.C. § 1116. Those diseases are listed in 38 C.F.R. § 3.309(e); chronic fatigue syndrome is not among the listed diseases. Therefore, the presumptive provisions of 38 U.S.C. § 1116 do not apply, and service connection for such a disability on a presumptive basis, as due to exposure to Agent Orange is not warranted. Notwithstanding the foregoing, a Veteran is not precluded from establishing service connection for diseases not subject to presumptive service connection with proof of actual direct causation. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Board finds that a VA examination is necessary to address direct causation of the claimed condition, as well as to obtain an opinion on whether the Veteran’s condition is secondary to or has been aggravated by his service-connected PTSD. 2. Entitlement to service connection for hypertension, to include as secondary to herbicide exposure and/or PTSD, is remanded. Regarding the claim for service connection for hypertension, to include as due to his service in the Republic of Vietnam, he has presumed herbicide exposure in service. The Veteran is also service-connected for PTSD. Although hypertension is not listed as a disease associated with herbicide exposure under the applicable regulations, the National Academy of Sciences Institute of Medicine (IOM) has concluded that there is “limited or suggestive evidence of an association” between herbicide exposure and hypertension. See 79 Fed. Reg. 2030877, 20310 (Apr. 11, 2014); Fed. Reg. 47,924, 47, 926-927 (Aug. 10, 2012). Additionally, an article in the November 2016 Journal of Occupational and Environmental Medicine entitled Herbicide Exposure, Vietnam Service, and Hypertension Risk in Army Chemical Corps Veterans suggests that herbicide exposure history and Vietnam service status were significantly associated with hypertension risk. See https://www.publichealth.va.gov/epidemiology/studies/vietnam-army-chemical-corps.asp. In addition, a VA study indicates a possible link between PTSD and heart disease. See http://www.research.va.gov/currents/spring2015/spring2015-8.cfm. The Board notes that the Veteran has not been afforded a VA examination for this condition. Accordingly, the Board finds that the Veteran should be provided an examination to determine the etiology of the Veteran’s hypertension. VA must provide an examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Thus, in light of the evidence (now including medical as well as lay evidence) of current CFS and hypertension conditions, and conceded exposure to herbicides due to his duty in Vietnam, the Veteran should be afforded a VA examination to address whether his disabilities are related to service including his herbicide exposure. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all treatment for hypertension and chronic fatigue syndrome. Obtain any identified records and associate them with the claims file. 2. Then schedule the Veteran for an examination to determine the nature and etiology of his chronic fatigue syndrome with fibromyalgia and encephalomyelitis. The Veteran’s claims file should be provided to and reviewed by the examiner. All indicated studies should be performed. Based on review of the record, the examiner should provide an opinion that responds to the following: (a) Is it at least as likely as not that the Veteran’s chronic fatigue syndrome with fibromyalgia and encephalomyelitis had its onset or is otherwise related to service, to specifically include exposure to herbicide agents? The opinion should include consideration and discussion of the Veteran’s presumed exposure to herbicide agents. (b) Is it at least as likely as not that the Veteran’s chronic fatigue syndrome with fibromyalgia and encephalomyelitis is caused by his service-connected PTSD? (c) Is it at least as likely as not that the Veteran’s chronic fatigue syndrome with fibromyalgia and encephalomyelitis is aggravated by his service-connected PTSD? A detailed rationale for any opinion expressed should be provided. If an opinion cannot be rendered without resorting to speculation, the examiner should state why that is so. 3. Then schedule the Veteran for an examination to determine the nature and etiology of his hypertension. The Veteran's claims file should be provided to and reviewed by the examiner. All indicated studies should be performed. Based on review of the record, and interview of the record, the examiner should provide an opinion that responds to the following: (a) Is it at least as likely as not that the Veteran’s hypertension had its onset or is otherwise related to service, to specifically include exposure to herbicide agents? The opinion should include consideration and discussion of the Veteran’s presumed exposure to herbicide agents and the IOM study and the November 2016 article regarding Agent Orange and hypertension referenced above. (b) Is it at least as likely as not that the Veteran’s hypertension is caused by his service-connected PTSD? (c) Is it at least as likely as not that the Veteran's hypertension is aggravated by his service-connected PTSD? A detailed rationale for any opinion expressed should be provided. If an opinion cannot be rendered without resorting to speculation, the examiner should state why that is so. (continued on next page) 4. After the development has been completed, readjudicate the claims on appeal. If any benefit sought remains denied, furnish the Veteran and his representative a supplemental statement of the case and return the case to the Board. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Michael J. O'Connor