Citation Nr: 18153866 Decision Date: 11/29/18 Archive Date: 11/28/18 DOCKET NO. 13-21 582A DATE: November 29, 2018a REMANDED Entitlement to service connection for gout is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for alcoholism/dementia is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from November 1967 to May 1970, which included service in the Republic of Vietnam. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a February 2011 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran provided testimony at a hearing before the undersigned Veterans Law Judge (VLJ) in June 2016. A transcript of this hearing is of record. In October 2016, the Board, in pertinent part, remanded the current appellate claims for further development. After the case was returned to the Board for additional appellate consideration, the Board also requested a medical expert opinion through the Veterans Health Administration (VHA) on the hypertension claim, and such an opinion was promulgated in May 2018. Despite the foregoing, for the reasons detailed below the Board finds that further development is still required for this appeal. 1. Entitlement to service connection for gout is remanded. In October 2016, the Board, in pertinent part, remanded the gout claim for a competent medical examination to clarify the etiology of this disability, to include the contention it was secondary to his service-connected diabetes mellitus and psychiatric disorder. The Board acknowledges the Veteran was accorded a VA examination in January 2017 which included an opinion against his gout being caused by the service-connected diabetes mellitus. However, it does not appear the examination addressed the issue of secondary aggravation as directed by the October 2016 remand. See also 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Without such an opinion, this examination is not adequate for resolution of this case. See El-Amin v. Shinseki, 26 Vet. App. 136, 138 (2013). In addition, the examination did not address whether the gout was secondary to the service-connected acquired psychiatric disorder as directed by the October 2016 remand directives. The Veteran has also indicated his gout is due to his alcohol use, which was another issue that was not addressed by the VA examinations conducted following the Board’s October 2016 remand. This further indicates the examinations are not adequate. Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, the Board concludes that a new remand is required to accord the Veteran a new competent medical examination which does adequately address his gout claim. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (When the medical evidence of record is insufficient, in the opinion of the Board, or of doubtful weight or credibility, the Board must supplement the record by seeking an advisory opinion, ordering a medical examination, or citing recognized medical treatises that clearly support its ultimate conclusions.). 2. Entitlement to service connection for hypertension is remanded. The Veteran has contended, in pertinent part, that his hypertension is due to in-service exposure to herbicide agents. Although the Veteran is presumed to have been exposed to herbicide agents during his active service in the Republic of Vietnam, hypertension is not listed as a disease presumptively associated with herbicide exposure under the applicable regulatory provisions of 38 C.F.R. § 3.309. Further, both the January 2017 VA examination and May 2018 VHA opinion concluded the Veteran’s hypertension was not related to his presumed in-service exposure to herbicide agents. In requesting an opinion on this issue from the VHA, the Board did note that the National Academy of Sciences Institute of Medicine (NAS) 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. Despite the foregoing, the Board notes that the NAS recently upgraded hypertension to the “sufficient” category from “limited or suggestive,” indicating that “there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. See November 15, 2018, press release from NAS. Consequently, the Board finds that a remand is required to address this development in the first instant below, to include a new competent medical examination/opinion in light of the NAS upgrade of hypertension to the “sufficient” category. 3. Entitlement to service connection for alcoholism/dementia is remanded. As detailed in the October 2016 remand, where drug and alcohol abuse is at issue, service connection is precluded “in two situations: (1) for primary alcohol abuse disabilities; and (2) for secondary disabilities (such as cirrhosis of the liver) that result from primary alcohol abuse.” Allen v. Principi, 237 F.3d 1368, 1376 (Fed. Cir. 2001). Service connection is not precluded if alcohol abuse is secondary to a service-connected disability, such as if a veteran has, as an example, PTSD and used alcohol and/or drugs to self-medicate. Id. Even if a veteran has a service-connected disability, however, service connection would be precluded for the alcohol or drug abuse disability if it is actually due to willful action rather than the result of the service-connected disability. Id., at 1378. The Board also found in October 2016 that the Veteran had submitted evidence which indicates he may satisfy an exception to the legal prohibition against establishing service connection for alcoholism. In pertinent part, he provided credible testimony at his June 2016 hearing that his alcohol use was a form of self-medication for his now service connected psychiatric disorder. However, the Board further found that the full nature and etiology of the current disability was not clear from the evidence of record. For example, it was not clear whether the Veteran does have dementia or any other chronic disability as a result of his alcohol use. Therefore, the Board remanded the claim for a competent medical examination and opinion to clarify whether the Veteran had a chronic disability due to his alcohol use, and if so, whether it is at least as likely as not the alcohol use was a form of self-medication for his psychiatric disorder. The Board acknowledges the Veteran was accorded a VA examination in January 2017 which noted he had stopped drinking in 1983; and that he was not demonstrating significant memory impairment on interview. However, the examiner also stated that formal neurocognitive testing was recommended to rule out dementing illness. It does not appear that such testing has been conducted, nor is it otherwise clear whether the Veteran has a chronic disability due to his alcohol use, and, if so, whether such alcohol use is due to his service-connected acquired psychiatric disorder. Consequently, the Board must conclude this examination is not adequate for resolution of this claim, and that a new competent medical examination and opinion is necessary. See Barr, supra; Colvin, supra. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records regarding the Veteran which cover the period from February 2017 to the present. 2. Request the Veteran identify names and addresses of all medical care providers who have treated the Veteran for gout, hypertension, and alcoholism/dementia from February 2017 to the present. After securing any necessary release, obtain those records not on file. 3. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of his in-service and post-service alcoholism/dementia, hypertension, and gout symptomatology. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 4. Schedule the Veteran for an examination by an appropriately qualified clinician to address the nature and etiology of his gout. The examiner should express an opinion as to whether it is at least as likely as not the gout was caused or aggravated by the Veteran’s service-connected diabetes mellitus and/or psychiatric disorder. The examiner should also address whether his gout was caused or aggravated by his alcohol use. By aggravation, the Board means a permanent increase in severity that is beyond natural progression. 5. Schedule the Veteran for an examination by an appropriately qualified clinician to address the nature and etiology of his hypertension. The examiner should express an opinion as to whether it is at least as likely as not it was incurred in or otherwise the result of his active service, to include his presumed exposure to herbicide agents while on active duty in the Republic of Vietnam. In making this determination, the examiner’s opinion should reflect consideration of the NAS’s recent upgrade of hypertension to the “sufficient” category indicating that “there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure.   6. Schedule the Veteran for an examination by an appropriately qualified clinician to clarify the nature of his claimed alcoholism disability. This examination should include any necessary testing, to include the formal neurocognitive testing recommended by the January 2017 VA examination. The examiner should express an opinion as to whether it is at least as likely as not the Veteran currently has alcoholism, dementia, gout or any other chronic disability as a result of his alcohol use. If so, the examiner should express an opinion as to whether it is at least as likely as not the alcohol use was a form of self-medication for his psychiatric disorder. The Board has already found his testimony to be credible. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD John Kitlas, Counsel