Citation Nr: 18154367 Decision Date: 11/29/18 Archive Date: 11/29/18 DOCKET NO. 16-51 625 DATE: November 29, 2018 REMANDED Entitlement to service connection for hypertension, to include as secondary to herbicide exposure and/or service-connected disease or injury (specifically diabetes mellitus type II and/or coronary artery disease), is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1966 to January 1968. The Board notes that, in addition to the claim for service connection for hypertension addressed herein, the Veteran has perfected appeals with respect to his claims for entitlement to service connection for posttraumatic stress disorder (PTSD) and peripheral vascular disease; entitlement to increased disability ratings for diabetes mellitus type II and coronary artery disease; and entitlement to a total disability rating based upon individual unemployability (TDIU). However, as he has requested a Board hearing in these matters, and such a hearing has not yet been held, the Board will not address them at this time. Service connection for hypertension The Veteran has advanced three theories of entitlement with respect to his claim for service connection: (1) that his hypertension is related to his exposure to herbicides in Vietnam; (2) that his hypertension is caused or aggravated by his service-connected diabetes mellitus type II; and (3) that his hypertension is caused or aggravated by his service-connected coronary artery disease. For the following reasons, the Board finds that a remand is warranted for additional evidentiary development. The record indicates that the Veteran was afforded a VA examination in November 2018, following which the examiner opined that the Veteran’s hypertension was less likely than not secondary to his diabetes mellitus type II. However, the examiner did not discuss whether the Veteran’s hypertension was aggravated by his diabetes mellitus type II or causally related to (i.e., caused or aggravated by) his coronary artery disease. See 38 C.F.R. § 3.310(b) (any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected). Consequently, an additional examination and opinion is needed to address these issues. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes to provide a medical examination or opinion, it must ensure that the examination or opinion is adequate). The Board further notes that although hypertension is not currently among the diseases which have been presumptively linked to herbicide exposure under 38 C.F.R. § 3.309(e), the National Academies of Sciences, Engineering, and Medicine (NAS) recently upgraded the likelihood of an association between hypertension and exposure to herbicides, to include Agent Orange, from “limited or suggestive” evidence of an association to “sufficient” evidence of an association. See Veterans and Agent Orange: Update 11 (2018) (available at http://nationalacademies.org/hmd/reports/2018/veterans-and-agent-orange-update-2018.aspx). Here, there are no medical opinions of record evaluating the Veteran’s contention that his exposure to herbicides in Vietnam caused his hypertension. Given the NAS findings discussed above, the Board finds that such an opinion should be provided as well. The matter is REMANDED for the following action: Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his hypertension. The examiner must respond to the following questions: (a) Is the Veteran’s hypertension at least as likely as not related to his exposure to herbicides, to include Agent Orange, as a result of his in-country service in Vietnam? The examiner must specifically address the November 2018 Veterans and Agent Orange: Update 11, citing a recent NAS report indicating that there is “sufficient” evidence of an association between hypertension and herbicide exposure. (b) Is the Veteran’s hypertension at least as likely as not aggravated by his service-connected diabetes mellitus type II? (c) Is the Veteran’s hypertension at least as likely as not caused or aggravated by his service-connected coronary artery disease? (Continued on the next page)   A full and well-reasoned rationale should be provided for all opinions reached. A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Minot, Associate Counsel