Citation Nr: 18152298 Decision Date: 11/21/18 Archive Date: 11/21/18 DOCKET NO. 16-51 276 DATE: November 21, 2018 REMANDED Entitlement to service connection for hypertensive vascular disease, including as due to herbicide exposure, and including as secondary to service-connected coronary artery disease (CAD), is remanded. Entitlement to service connection for a left lower extremity disability, including as due to herbicide exposure, is remanded. Entitlement to service connection for a right lower extremity disability, including as due to herbicide exposure, is remanded. REASONS FOR REMAND The Veteran had active service in the Army from August 1969 to August 1971. This matter came before the Board of Veterans’ Appeals (Board) on appeal from an August 2015 rating decision issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran’s DD 214 forms show that he served in the Republic of Vietnam for nearly 11 months. They also show that he was awarded the Vietnam Service Medal, the Vietnam Campaign Medal with 60 Device, and the Combat Infantryman Badge. As such, exposure to herbicides is conceded. 38 U.S.C. § 1116 (f), 38 C.F.R. § 3.307(a)(6)(iii). 1. Entitlement to service connection for hypertensive vascular disease, including as due to herbicide exposure, and including as secondary to service-connected CAD, is remanded. Service connection may be granted on a presumptive basis for certain diseases associated with exposure to certain herbicide agents, even though there is no record of such disease during service, if they manifest to a compensable degree any time after service, in a veteran who had active military, naval, or air service for at least 90 days, during the period beginning on January 9, 1962 and ending on May 7, 1975, in the Republic of Vietnam, including the waters offshore, and other locations if the conditions of service involved duty or visitation in Vietnam. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309(e), 3.313. Hypertension is not a disability subject to presumptive service connection due to herbicide exposure. 38 C.F.R. § 3.309(e). Notwithstanding the foregoing presumption provisions for herbicide exposure, a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). In the instant case, the Veteran asserted that he is entitled to service connection for hypertensive vascular disease (also known as hypertension) on a presumptive basis due to herbicide exposure during his service in Vietnam, or in the alternative, as secondary to his service-connected CAD. As noted above, hypertension is not a disability subject to presumptive service connection due to herbicide exposure. Therefore, the Veteran is not entitled to service connection for hypertension, as due to herbicide exposure, on a presumptive basis. However, he is eligible to claim service connection on a direct basis. Combee, 34 F.3d at 1042. As part of his claim, the Veteran submitted a November 2016 medical study by the U.S. National Library of Medicine National Institutes of Health that examined hypertension risk in Army Chemical Corps (ACC) veterans who sprayed defoliant in Vietnam. The study found that exposure to herbicides and Vietnam service status were significantly associated with hypertension risk. The Veteran was provided with a VA examination in July 2015, which addressed his hypertension disability. However, the examiner only opined as to whether the Veteran’s hypertension was proximately due to or a result of his service-connected CAD. The Board cannot make a fully-informed decision on the issue of direct service connection because no VA examiner has opined whether there is a causal relationship between the Veteran’s hypertension disability and his exposure to herbicides during his service in Vietnam. As such, an addendum medical opinion is warranted to address this question. In relation to the Veteran’s assertion for entitlement to secondary service connection, an addendum medical opinion is warranted. Secondary service connected can be established if there is evidence that the non-service connected disability is either proximately due to or the result of a service-connected disability, or aggravated beyond its natural progress by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Although the Veteran’s July 2015 VA examination provided a medical opinion regarding secondary service connection, the medical opinion only addressed the first element of secondary service connection and did not address whether the Veteran’s hypertension was aggravated beyond its natural progress by his CAD. The medical evidence confirms that the Veteran’s diagnosis of hypertension in 1995 predates his diagnosis of CAD in 2014. Therefore, while it is less likely than not, according to the July 2015 VA examiner, that the Veteran’s hypertension was proximately due to or the result of CAD, it remains a possibility that the Veteran’s hypertension was aggravated beyond its natural progress by his CAD. The Board cannot make a fully-informed decision on the issue of secondary service connection because no VA examiner has opined whether the Veteran’s hypertension was aggravated beyond its natural progress by his CAD. As such, the Veteran must be afforded an addendum medical opinion to address the second prong of the secondary service connection test. 2. Entitlement to service connection for neuropathy of the left lower extremity, including as due to herbicide exposure, is remanded. 3. Entitlement to service connection for neuropathy of the right lower extremity, including as due to herbicide exposure, is remanded. Early-onset neuropathy is a disability subject to presumptive service connection due to herbicide exposure. 38 C.F.R. § 3.309(e). However, for a Veteran to be entitled to service connection for early-onset neuropathy pursuant to the presumption of herbicide exposure, the Veteran’s neuropathy must have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval or air service. 38 C.F.R. 3.307(a)(6)(ii). In the instant case, the Veteran stated that he has experienced symptoms of neuropathy in his lower extremities since approximately 2011. Therefore, the Veteran is not entitled to service connection for early-onset neuropathy of the lower extremities, as due to herbicide exposure, on a presumptive basis. However, he is eligible to claim service connection on a direct basis. Combee, 34 F.3d at 1042. The Veteran’s most recent medical consultation regarding his neuropathy disability was in September 2016 at the neurology department of the Salem VA medical center. The examiner reported that the Veteran had “moderate chronic polyneuropathy most likely metabolic syndrome only lacking laboratpry evidence of diabetes.” During a July 2016 assessment by a private rheumatology group, the examiner provided the following opinion: “Advised to consider neurology evaluation for neuropathy. Patient has had exposure to agent orange in the past and given that he is not a diabetic, that may need to be considered as as possible connection. Would defer to neurologic expertise to determine.” During a June 2015 private primary care consultation, the examiner opined that the Veteran’s peripheral neuropathy “may be related to the back.” During a December 2014 rehabilitation medicine evaluation, the examiner opined that the Veteran’s neuropathy “could be from undertreated hypothydoidism given recent increased TSH...However, I have ordered blood work to rule out other treatable causes of neuropathy.” The Veteran has not been afforded a DBQ examination by the VA for neuropathy of his lower extremities. As there are differing medical opinions regarding the etiology of the Veteran’s neuropathy, the Board cannot make a fully-informed decision on the issue of service connection for neuropathy of the lower extremities without a VA examination and medical opinion addressing whether there is a causal relationship between the Veteran’s exposure to herbacides during his service in Vietnam and his neuropathy disability. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s hypertension is at least as likely as not related to in-service herbicide agent exposure. The examiner should also provide an addendum opinion regarding whether the Veteran’s hypertension was aggravated beyond its natural progression by his service-connected cardiovascular disease. The electronic claims file, to include the Veteran’s service treatment records, lay statements and testimonies, treatment records, and medical articles relating to hypertension noted in the Informal Hearing Presentation must be reviewed by the examiner, and a note that it was reviewed should be included in the report. All findings, conclusions, and opinions must be supported by a clear rationale. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his neuropathy of the lower extremities. The DBQ should be filled out completely as relevant. The electronic claims file, to include the Veteran’s service treatment records, lay statements and testimonies, and treatment records, must be reviewed by the examiner, and a note that it was reviewed should be included in the report. After reviewing the claims file and examining the Veteran, the examiner must opine whether the Veteran’s neuropathy of the lower extremities is at least as likely as not related to any disease or injury of service origin, on to the conceded in-service herbicide agent exposure. All findings, conclusions, and opinions must be supported by clear rationale. 3. If the examiners are unable to offer the requested opinion, it is essential that the examiners offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to 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. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). (Continued on the next page)   4. Then, after conducting any other development deemed necessary, readjudicate the Veteran’s claims. If any benefits sought on appeal remain denied, provide the Veteran and his representative with a supplemental statement of the case (SSOC) and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board. Michael Pappas Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. White, Associate Counsel