Citation Nr: 18160121 Decision Date: 12/21/18 Archive Date: 12/21/18 DOCKET NO. 11-22 947 DATE: December 21, 2018 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD), type II diabetes mellitus type II (diabetes) with erectile dysfunction, chronic kidney disease associated with diabetes, and/or herbicide agent exposure, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from October 1961 to August 1962 and September 1963 to February 1983, which included combat service in Vietnam and receipt of a Purple Heart medal and Vietnam Cross of Gallantry with Palm. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2009 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2013, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge. In a July 2017 decision, the Board denied the Veteran’s appeal for direct service connection for hypertension due to herbicide agent exposure and for secondary service connection for hypertension due to diabetes and PTSD. The Board granted the Veteran’s claims for entitlement to a total disability rating based on individual unemployability (TDIU) and special monthly compensation (SMC) at the housebound rate. The Veteran timely appealed the July 2017 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a June 2018 Order, pursuant to a Joint Motion for Partial Remand (JMPR) submitted by the parties, the Court vacated and remanded the Board decision’s as to direct and secondary service connection for hypertension. The Court noted it would not disturb the Board’s favorable findings as to entitlement to TDIU and SMC and dismissed these remaining issues. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD, diabetes with erectile dysfunction, chronic kidney disease associated with diabetes, and/or herbicide agent exposure is remanded. The Veteran maintains that borderline hypertension had its onset during service and that his hypertension is due to herbicide agent exposure (conceded due to Vietnam service) and/or is secondary to his service-connected PTSD, diabetes, or chronic kidney disease associated with diabetes. The Veteran was afforded VA examinations with nexus opinions rendered in February 2009, May 2009, and May 2015, and an addendum opinion rendered in June 2016. However, the Court determined all four opinions to be inadequate. Additionally, the Veteran is now service-connected for chronic kidney disease associated with diabetes, and there is no opinion of record on the relationship between this disorder and hypertension. Thus, on remand new medical nexus opinions on direct and secondary service connection are warranted to encompass all the Veteran’s theories of entitlement. Any outstanding treatment records should also be secured. The matter is REMANDED for the following action: 1. Obtain any outstanding VA treatment records. 2. With any necessary assistance from the Veteran, obtain any outstanding relevant private treatment records. 3. Then obtain an addendum opinion addressing the etiology of the Veteran’s hypertension. The claims file, including a copy of this remand, must be provided to the examiner in conjunction with the requested opinion. No additional examination of the Veteran is needed, unless the examiner determines otherwise. The examiner should address the following: Please opine on whether it is at least likely as not (a 50 percent or greater probability) that diagnosed hypertension: (i) had its onset in service or is otherwise related to service, to include as a result of conceded exposure to herbicide agents therein; (ii) is proximately due to his service-connected PTSD; (iii) has been aggravated (worsened beyond natural progression) by his service-connected PTSD; (iv) is proximately due to his service-connected diabetes; (v) has been aggravated (worsened beyond natural progression) by his service-connected diabetes; (vi) is proximately due to his service-connected chronic kidney disease associated with diabetes; or (vii) has been aggravated (worsened beyond natural progression) by his service-connected chronic kidney disease associated with diabetes. In addressing question (i), please address the Veteran’s presumed exposure to herbicide agents, do not rely on the lack of availability of presumptive service connection for hypertension, and please discuss the National Academy of Sciences Institute of Medicine’s conclusion that there is “limited or suggestive evidence of an association” between herbicide agent exposure and hypertension. See 77 Fed. Reg. 47924, 47926-927 (Aug. 10, 2012). The examiner should note that inquires (ii) –(vii) require two opinions: one for proximate causation and one for aggravation. In addressing questions (ii) and (iii), the examiner must comment on the medical studies addressing a relationship between PTSD and cardiovascular disease, namely “Presumptions of Service Connection for Diseases Associated with Service Involving Detention or Internment as a Prisoner of War” and “VA National Center for PTSD, Kay Jankowski, PTSD and Physical Health.” In addressing questions (iv) and (v), please note that it is not necessary that diabetes be service-connected, or even diagnosed, at the time his hypertension is incurred, and reliance on this fact in support of a negative opinion will render it inadequate. A complete rationale must be provided for all opinions expressed. If for any reason the examiner is unable to provide a medical opinion, he or she should provide a rationale for that conclusion (e.g. whether there is any 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). S. BUSH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Asante, Associate Counsel