Citation Nr: 18159323 Decision Date: 12/18/18 Archive Date: 12/18/18 DOCKET NO. 17-02 043 DATE: December 18, 2018 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to a rating in excess of 30 percent for coronary artery disease (CAD), status post-bypass surgery, is remanded. REASONS FOR REMAND 1. Entitlement to service connection for hypertension. The Veteran contends that he is entitled to service connection for his currently diagnosed hypertension as secondary to his service connected diabetes mellitus, type II. He argues that VA failed to adequately assist him in substantiating his claim. He also contends that VA failed to consider medical journal articles he submitted in support of his claim. See December 2018 Form 9; see also September 2018 Statement of Accredited Representative. To ensure VA has met its duty to assist, the Board finds that remand is necessary for a medical opinion as to whether the Veteran’s hypertension is at least as likely as not as caused or aggravated by exposure to herbicide agent, including Agent Orange, during his active duty service in the Republic of Vietnam. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (holding that the duty to assist requires VA to provide a medical opinion where the evidence “indicates” that there “may” be a nexus between the in-service injury or event and current disability). It is undisputed that the Veteran has a present diagnosis of hypertension, and is service connected for diabetes mellitus as a result of exposure to herbicide agents, including Agent Orange, during active duty service in Vietnam. Private treatment records dated between 2010 and 2013 show the Veteran had risk factors for hypertension including smoking, obesity, inactivity, no special diet, and a family history of hypertension. A May 2013 VA examination determined that the Veteran’s hypertension was not caused or aggravated by his diabetes mellitus because his hypertension was diagnosed decades after separation from active service and because the Veteran had normal renal function. Although VA has not conceded a relationship between hypertension and Agent Orange, it is significant to note that the National Academies of Sciences, Engineering, and Medicine (NAS) recently found “sufficient” evidence of an association for hypertension and exposure to Agent Orange and other herbicides used during the Vietnam War. See National Academies of Sciences, Engineering, and Medicine. 2018. Veterans and Agent Orange: Update 11 (2018). Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25137. “The sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. The NAS updates are published in the Federal Register by VA, and thus VA is on notice as to the information contained therein. The suggestive evidence of an association arguably can be sufficient to establish an “indication” that the Veteran’s hypertension “may be related” to herbicide exposure during service, as contemplated by 38 U.S.C. § 5103A(d)(2)(B). Thus, remand is warranted for further consideration of the etiology of the Veteran’s hypertension. It is noted that the Veteran has reported that there is relevant treatise evidence in support of his claim. He should provide to VA copies of any relevant evidence he would like considered in this matter. 2. Entitlement to a rating in excess of 30 percent for CAD, status post bypass surgery. The Veteran contends that his CAD should be evaluated at 60 percent disabling because private medical evidence shows his METs and left ventricle ejection fraction (LEVF) are worse than evaluated by VA. Specifically, he argues that VA failed to use the best available studies to measure the severity of his disability. He also argues that VA failed to consider carotid artery blockage in assessing the severity of his disability. See December 2018 Form 9; see also September 2018 Statement of Accredited Representative; July 2013 Notice of Disagreement. The Board concludes that remand is warranted for a new VA examination to consider the severity of the Veteran’s CAD. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (The duty to assist is a two-way street; if the veteran has relevant evidence he should provide this and not passively wait in such circumstances). Accordingly, the matters are REMANDED for the following actions: 1. Obtain any outstanding relevant VA and private medical records. 2. Request from the Veteran copies of any relevant treatise evidence he believes supports his claim for service connection for hypertension, which he would like specifically considered in this matter. 3. Obtain from a qualified clinician an opinion as to the nature and etiology of the Veteran’s hypertension. The clinician should review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post service medical records, lay statements, and any associated treatise-type evidence. An examination is not required unless deemed necessary to provide the clinician providing the requested opinion. The clinician should opine on the following: whether it is at least as likely as not that the Veteran’s hypertension: (i) manifested during active service, (ii) manifested to a compensable degree within one year after active service, (ii) is otherwise etiologically related to his military service, including herbicide exposure therein (notwithstanding the fact that it may not be a presumed association), (iv) is proximately due to service-connected diabetes, and/or (v) aggravated beyond normal progression by service-connected diabetes. The clinician should consider the the 2018 NAS Update reference above when formulating an opinion in these matters along with any relevant treatise evidence of record from the Veteran or his representative. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected heart disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner is requested to provide diagnostic METs scores. If these tests cannot or should not be undertaken, the examiner should provide an explanation for such finding, as well as an estimation of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope. It is insufficient for the examiner only to note that the Veteran does not experience symptoms with any level of physical activity as a reason for not providing METs scores. The examiner should address the Veteran’s contention that two-dimensional diagnostic imaging is insufficient to measure the severity of CAD symptoms. 5. Ensure that both VA medical opinions include a complete rationale for the conclusions reached. The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include 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. (Continued on the next page)   6. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Gillian A. Flynn, Associate Counsel