Citation Nr: 18156763
Decision Date: 12/11/18	Archive Date: 12/10/18

DOCKET NO. 12-21 834
DATE:	December 11, 2018
REMANDED
Service connection for right leg peripheral vascular disease with right below knee amputation is remanded.
Service connection for left leg peripheral vascular disease is remanded.
Service connection for hypertension is remanded.
REASONS FOR REMAND
The Veteran served on active duty from February 1969 to November 1971. 
In February 2015, the Board remanded this appeal for further development.
Although the Board sincerely regrets the additional delay, a remand is necessary to ensure that there is a complete and accurate record upon which to decide the Veteran’s claim so that every possible consideration is afforded.
The Veteran’s service in the Republic of Vietnam creates a presumption that he was exposed to herbicides while on active duty.  38 C.F.R. § 3.307(a) (6) (iii).  The Veteran was afforded VA examinations in October 2011 and December 2015.  The October 2011 examiner opined that the Veteran’s peripheral vascular disease was related to his hypertension.  Subsequent to the December 2015 VA examination, the National Academy of Science (NAS) issued the 2018 Veterans and Agent Orange Update, which in turn found “sufficient” evidence of an association between hypertension and herbicide agent exposure.  Therefore, a new examination must be obtained to consider this new finding.  In addition, the claims for right and left leg peripheral vascular disease are inextricably intertwined with the claim for hypertension and consideration of those claims must be deferred.
The matters are REMANDED for the following action:
Request a records review and medical opinion from an appropriately qualified clinician to determine the etiology of the Veteran’s hypertension.  The entire claim file should be made available to and be reviewed by the clinician in conjunction with this request.  
The reviewing clinician is asked to respond to the following:
A)	Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s hypertension began in service or is related to any incident in service, to include exposure to herbicide agents?
The reviewing clinician should consider the NAS’s 2018 Agent Orange Update in formulating his/her opinion.
The Veteran’s exposure to herbicide agents is presumed since he served in Vietnam during the Vietnam era.  The reviewing clinician must provide a detailed explanation of the medical opinion provided, but cannot base the opinion solely on the fact that VA does not recognize a presumptive relationship between the Veteran’s specific condition and past exposure to herbicide agents.  Thus, the opinion and associated rationale needs to address the likelihood that this Veteran’s hypertension was related to herbicide agent exposure given his individual medical history, family history, risk factors, etc.
A detailed explanation (rationale) is requested for all opinions provided.  (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation.  Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested).
If the requested opinion cannot be provided without resort to speculation, the examiner should state this AND must explain why an opinion cannot be provided without resort to speculation (including whether an opinion is beyond what any medical practitioner might be able to provide, based on the evidence of record and current medical knowledge).
 
DONNIE R. HACHEY
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	M. D’Allaird, Associate Counsel