Citation Nr: 18149313 Decision Date: 11/09/18 Archive Date: 11/09/18 DOCKET NO. 08-37 163A DATE: November 9, 2018 REMANDED Entitlement to service connection for hypertension, to include as due to exposure to herbicide agents and as secondary to service-connected coronary artery disease (CAD) and/or posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for myelopathy, to include as due to exposure to herbicide agents and as secondary to service-connected disabilities is remanded. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities, to include as due to exposure to herbicide agents and as secondary to service-connected disabilities is remanded. Entitlement to service connection for peripheral neuropathy of the bilateral upper extremities, to include as due to exposure to herbicide agents and as secondary to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1968 to June 1970, including service in the Republic of Vietnam. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a May 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. The May 2007 rating decision denied the Veteran’s petition to reopen claims for entitlement to service connection for peripheral neuropathy of the upper and lower extremities and denied entitlement to service connection for myelopathy and hypertension. The Board in an April 2016 decision, granted the Veteran’s petition to reopen the issues of entitlement to service connection for peripheral neuropathy of the bilateral upper and lower extremities and remanded them along with entitlement to service connection for myelopathy and hypertension, for further development. In September 2017, the issues were again before the Board and were remanded. Service connection for hypertension, myelopathy, and peripheral neuropathy of the bilateral upper and lower extremity is remanded In its September 2017 remand, the Board requested that the RO send the Veteran a VA Form 21-4142 (Authorization and Consent to Release Information) to obtain outstanding VA treatment records since December 2014. These two directives have been completed. The Board also requested a medical opinion addressing the nature and etiology of the Veteran’s peripheral neuropathy, myelopathy, and hypertension. The November 2017 VA opinions were inadequate as they did not respond to both prongs of a secondary service connection claim. To be adequate, a VA opinion must provide separate rationales for both causation and aggravation. Atencio v. O’Rourke, 30 Vet. App. 74 (2018). The Veteran is entitled to substantial compliance with Board remand requests. Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141 (1999). Accordingly, the matters are REMANDED for the following action: 1. Provide the Veteran’s claim file to a qualified clinician so that a supplemental opinion may be provided addressing the etiology of his hypertension. A new examination is only required if deemed necessary by the examiner. The entire claims file and a copy of this remand must be made available to the examiner for review. Although an independent review of the claims file is required, the Board calls the examiner’s attention to the following: a. A February 2001 notation indicates a “history of hypertension.” b. A February 2006 letter from one of his private physicians, Dr. P. L. B., who has treated the Veteran for his hypertension for many years, which states that his hypertension is an “aspect of his PTSD.” c. The Veteran’s contentions that his hypertension is caused by his PTSD and that his PTSD has caused severely increased anxiety which aggravates his hypertension. d. Studies and medical treatises, including Diseases Among Men 20 Years After Exposure to Severe Stress Implications for Clinical Research and Medical Care (Boscarino, J. A., Psychosom Med 1997), showing a relationship between hypertension and PTSD and hypertension and CAD. The examiner should then address the following: a. Whether it is at least as likely as not (at least a 50 percent probability) that the Veteran has hypertension that is related to service or any incidents therein, to include his presumed herbicide exposure, or began within one year after discharge from active service. It is not sufficient to provide a negative opinion regarding whether the disability was due to herbicide exposure solely because it is not on the list of disabilities presumptively associated with herbicide exposure. a. Whether it is at least as likely as not (50 percent or greater probability) that the hypertension was proximately due to or the result of his service-connected disabilities of PTSD and/or CAD. b. Whether it is at least as likely as not that the hypertension was aggravated beyond its natural progression by his service-connected disabilities of PTSD and/or CAD. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 2. Provide the Veteran’s claim file to a qualified clinician so that a supplemental opinion may be provided addressing the etiology his myelopathy. A new examination is only required if deemed necessary by the examiner. The entire claims file and a copy of this remand must be made available to the examiner for review. Although an independent review of the claims file is required, the Board calls the examiner’s attention to the following: a. September 2005 dated letter from Dr. L. M., noting that the Veteran was “presently” being treated by him “for a progressive polyneuropathy and myelopathy of unknown cause… The possibility of an Agent Orange-related phenomenon should at least be considered.” b. January 2006 diagnosis of myelopathy. The examiner should then address the following: a. Whether it is at least as likely as not (at least a 50 percent probability) that the Veteran has myelopathy that is related to service or any incidents therein, to include his presumed herbicide exposure. It is not sufficient to provide a negative opinion regarding whether the disability was due to herbicide exposure solely because it is not on the list of disabilities presumptively associated with herbicide exposure. b. Whether it is at least as likely as not (50 percent or greater probability) that the myelopathy was proximately due to or the result of his service-connected disabilities, to include PTSD, CAD, headaches, irritable bowel syndrome, tinnitus, hearing loss, and erectile dysfunction. c. Whether it is at least as likely as not that the myelopathy was aggravated beyond its natural progression by his any service-connected disabilities, to include PTSD, CAD, headaches, irritable bowel syndrome, tinnitus, hearing loss, and erectile dysfunction. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 3. Provide the Veteran’s claim file to a qualified clinician so that a supplemental opinion may be provided addressing the etiology his peripheral neuropathy of the bilateral lower and bilateral upper extremities. A new examination is only required if deemed necessary by the examiner. The entire claims file and a copy of this remand must be made available to the examiner for review. Although an independent review of the claims file is required, the Board calls the examiner’s attention to the following: a. VA medical treatment notes indicating an August 1983 notation that the Veteran complained of a pinching feeling in his left buttock for ten years and pain in the left leg for one week. b. June 1991 complaints of pain, swelling, and redness in his left medial knee region, including the calf and the thigh. A diagnosed of phlebitis was rendered. c. June 1991, dated letter from L. A. L, the Veteran’s sister (a nurse) stating that during Basic Training, the Veteran experienced edema of both legs and ankles and the symptoms persisted at Ft. Polk where he was “barely able to complete the required training … since running caused pain and edema in his legs.” d. April 2001 dated letter from Dr. J. J. G., indicating that the Veteran’s complaints of “dysfunction of the legs, [with] the left greater than the right … with diminished vibrations perception at least suggest the possibility of neuropathy.” e. September 2005 dated letter from Dr. L. M., noting that the Veteran was “presently” being treated by him “for a progressive polyneuropathy and myelopathy of unknown cause… The possibility of an Agent Orange-related phenomenon should at least be considered.” f. VA treatment records showing a January 2006 diagnosis of neuropathy. The examiner should then address the following: a. Whether it is at least as likely as not (at least a 50 percent probability) that the Veteran has peripheral neuropathy of the bilateral lower extremities and/or bilateral upper extremities that is related to service or any incidents therein. b. Whether it is at least as likely as not (at least a 50 percent probability) that the Veteran’s peripheral neuropathy of the bilateral lower extremities and/or bilateral upper extremities is directly related to his exposure to herbicide agents. It is not sufficient to conclude that the Veteran’s peripheral neuropathy of the bilateral lower extremities and/or bilateral upper extremities is not related to service solely because his type of neuropathy is not on the list of diseases and conditions presumptively associated with exposure to herbicide agents. c. Whether it is at least as likely as not (50 percent or greater probability) that the peripheral neuropathy of the bilateral lower extremities and/or bilateral upper extremities was proximately due to or the result of his any service-connected disabilities, to include PTSD, CAD, headaches, irritable bowel syndrome, tinnitus, hearing loss, and erectile dysfunction. d. Whether it is at least as likely as not that the peripheral neuropathy of the bilateral lower extremities and/or bilateral upper extremities was aggravated beyond its natural progression by his any service-connected disabilities, to include PTSD, CAD, headaches, irritable bowel syndrome, tinnitus, hearing loss, and erectile dysfunction. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 4. Then, readjudicate the claims for service connection for hypertension, myelopathy, and peripheral neuropathy of the bilateral upper and lower extremities. If any decision is unfavorable to the Veteran, issue a supplemental statement of the case and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Stevens, Associate Counsel