Citation Nr: 18158025
Decision Date: 12/14/18	Archive Date: 12/13/18

DOCKET NO. 16-20 206
DATE:	December 14, 2018
REMANDED
Service connection for hypertension is remanded.
Service connection for erectile dysfunction is remanded.
REASONS FOR REMAND
The Veteran served on active duty from January 1966 to February 1970 to include service in Vietnam. He appeals a February 2013 rating decision that denied these claims.
1. Service connection for hypertension is remanded.
The Veteran advances multiple theories in this claim, to include that hypertension is due to conceded Agent Orange exposure in Vietnam. VA examination in March 2016 does not address the Agent Orange theory.
Since the May 2017 VA examination, as noted in Veterans and Agent Orange: Update 11 (2018), the National Academy of Sciences (NAS), found sufficient evidence of an association for hypertension and exposure to Agent Orange and other herbicides used during the Vietnam War. Hypertension has been upgraded from its previous classification in the category of “limited or suggestive” evidence of an association to the category of “sufficient” evidence of an association.  According to NAS, “[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure.
Accordingly, a remand is necessary for VA examination.
2. Service connection for erectile dysfunction is remanded.
The Veteran also advances multiple theories in this claim, to include that it is also due to conceded Agent Orange exposure in Vietnam or service-connected prostate cancer. A November 2018 VA contract prostate examination finds that erectile dysfunction is due to hypertension medication, as opposed to prostate cancer, but provides no rationale, while a July 2016 VA contract prostate examination attributes erectile dysfunction to prostate cancer. It is noted that he was diagnosed with prostate cancer in early 2016 following several years of negative biopsies despite having symptoms.
The Board cannot make a fully-informed decision on this issue because no VA examiner has opined, based upon a review of the entire record, and with an adequate supporting rationale, whether erectile dysfunction, noted in the record since 1997, is related to service, to include conceded Agent Orange exposure therein, or to service-connected prostate cancer. While erectile dysfunction is not afforded presumptive service connection based on Agent Orange exposure, a medical opinion should be obtained addressing entitlement to service connection on a direct basis. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Accordingly, a remand is necessary for VA examination.
The matters are REMANDED for the following action:
1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his hypertension. The examiner must opine whether it is at least as likely as not related to service.  
The examiner should also opine whether it at least as likely as not began during active service or manifested within the initial year after discharge from service.
The examiner should also opine whether the Veteran’s hypertension is at least as likely as not related to in-service herbicide agent exposure. The examiner should consider the NAS 2018 conclusion that hypertension has been upgraded from its previous classification in the category of “limited or suggestive” evidence of an association to the category of “sufficient” evidence of an association.  According to NAS, “[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure.
A complete rationale for all opinions is requested.
2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran’s erectile dysfunction. Upon review of the Veteran’s claims file, and after performing examination and any necessary testing, the examiner should provide response to the following questions: 
Is the Veteran’s erectile dysfunction at least as likely as not related to in-service herbicide agent exposure;
 

Is it at least as likely as not that any erectile dysfunction was caused or aggravated by his service-connected prostate cancer or medication for the same? The examiner should also address the theory that it is due to hypertension. 
A complete rationale for all opinions is requested.
 
H. N. SCHWARTZ
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	N. RIPPEL