Citation Nr: 18160128 Decision Date: 12/21/18 Archive Date: 12/21/18 DOCKET NO. 14-26 348 DATE: December 21, 2018 REMANDED Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1951 to June 1954, March 1958 to March 1962, and April 1962 to June 1975. This matter comes to the Board of Veterans’ Appeals (Board) from a May 2013, rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. This claim was previously before the Board in July 2017, at which time it was remanded for an addendum VA medical opinion. The claim has now returned to the Board for further appellate action. Entitlement to service connection for hypertension is remanded. Unfortunately, another remand is required in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran’s claim for service connection for hypertension, so that the Veteran is afforded every possible consideration. The October 2018 VA examiner did not provide an adequate and clear rationale for the negative nexus opinion with respect to aggravation by service-connected atherosclerotic coronary artery disease (CAD), and presumptive service connection based on exposure to Agent Orange. Accordingly, the Board finds that the evidence of record does not contain sufficient competent medical evidence to determine if the Veteran’s hypertension is caused or related to the Veteran’s active duty service or service-connected disability, and that therefore, further development is warranted with respect to the claim. 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The matter is REMANDED for the following actions: 1. Obtain an addendum VA medical opinion from an appropriate examiner, other than the October 2018 VA examiner, to determine the nature and etiology of the Veteran’s claim for entitlement to service connection for hypertension. The claims file, including this remand, must be made available to the examiner for review, and the VA examination report should reflect that such review was accomplished. The examiner must offer specific responses for each of the following: (a) Whether it is as likely as not (a 50 percent probability or greater) that the Veteran’s hypertension is caused by service-connected atherosclerotic coronary artery disease (CAD). (b) Whether it is as likely as not (a 50 percent probability or greater) that the Veteran’s hypertension is aggravated (permanently worsened beyond natural progression) by service-connected atherosclerotic CAD. (c) Whether it is as likely as not (a 50 percent probability or greater) that the Veteran’s hypertension is related to his military service. The examiner is advised that the Veteran is presumed to have been exposed to herbicide agents (Agent Orange) during his service in Vietnam. The opinion should include consideration of the Veteran's presumed exposure to certain herbicide agents, such as Agent Orange, as the National Academy of Sciences Institute of Medicine (NAS) has concluded that there is "limited or suggestive evidence of an association" between herbicide exposure and hypertension. A well-reasoned opinion, not just a restatement of NAS’s conclusion, relating to this consideration must be given for the examiner’s response to (c). A complete and clear rationale must be provided for all findings and conclusions reached. If the examiner determines that an opinion cannot be provided without resort to speculation, the examiner should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be rendered because the limits of medical knowledge have been exhausted regarding the etiology of the Veteran’s claim or whether additional information could be obtained that would lead to a conclusive opinion. The AOJ should ensure that any additional evidentiary development suggested by the examiner is undertaken so that a definite opinion can be obtained. 2. After the above development has been completed, the Agency of Jurisdiction (AOJ) should readjudicate the issue on appeal. If the benefit sought is not granted, the AOJ should send the Veteran and his representative a Supplemental Statement of the Case, provide an opportunity to respond, and then, if necessary, return the case to the Board for further appellate review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J.B. King, Associate Counsel