Citation Nr: 20002822 Decision Date: 01/13/20 Archive Date: 01/13/20 DOCKET NO. 17-61 729 DATE: January 13, 2020 REMANDED Entitlement to service connection for hypertension, to include as secondary to the service-connected disability of diabetes mellitus, type II is remanded. Entitlement to service connection for obstructive sleep apnea, to include as secondary to the service-connected disability diabetes mellitus, type II is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1971 to December 1973. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In October 2019, the Veteran and his spouse testified at a hearing before the undersigned Veterans Law Judge. A transcript is of record.   1. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus, type II is remanded 2. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected diabetes mellitus, type II is remanded The Veteran asserts hypertension and sleep apnea are related to his service-connected diabetes mellitus Type, II. At the hearing before the undersigned, the Veteran asserted that the metabolic process is part of the diabetic process, and that because of metabolic syndrome, he developed hypertension and sleep apnea. He indicated that neither condition was diagnosed or treated in service; he noted both were found in 1996. In January 2016 and October 2019, in support of his appeal, the Veteran provided excerpts from medical literature about the metabolic syndrome process and insulin resistance. The Veteran also submitted opinions from Dr. M.M. dated in October 2015 and November 2019. Dr. M.M. opined that the Veteran’s sleep apnea and hypertension are more likely than not secondary to his dysmetabolic syndrome, i.e. diabetes mellitus Type II. Dr. M.M.’s rationale was that the Veteran was diagnosed with diabetes in 2002, but evidence shows a person can be pre-diabetic for years prior. Dr. M.M. opined that the Veteran’s weight gain over the years due to dysmetabolic syndrome resulted in hyperinsulinemia. The Veteran has not been afforded a VA examination and the Board finds that a medical examination and/or opinion along with a fully-explained rationale would be helpful in deciding the claim. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 70 (2006). In the alternative, the Veteran asserts that his hypertension and sleep apnea may be related to his exposure to herbicide agents during service. The Board previously determined that the Veteran had “qualifying” service in the Republic of Vietnam such that exposure to herbicide agents is conceded. A medical opinion as to whether the Veteran's hypertension and/or sleep apnea is a result of the presumed exposure to herbicide agents in Vietnam would be helpful, particularly in light of the NAS upgrade of hypertension to the "sufficient" category from "limited or suggestive," indicating that "there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and herbicide exposure. See Veterans and Agent Orange: Update 11 (2018). The matters are REMANDED for the following action: Schedule the Veteran for a VA examination to determine the nature and etiology of his hypertension and sleep apnea. The claims file and a copy of this Remand must be made available for review. The examiner is to address the following: a. Is it at least as likely as not that the Veteran’s current hypertension and/or sleep apnea onset in service, or are otherwise related to service, to include his presumed exposure to herbicide agents? The examiner must provide a fully-explained rationale for the opinions provided. In formulating the opinions, the examiner is to consider the NAS upgrade of hypertension to the "sufficient" category from "limited or suggestive," indicating that "there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and herbicide exposure. See Veterans and Agent Orange: Update 11 (2018). b. Is it at least as likely as not that the Veteran’s current hypertension and/or sleep apnea are proximately due to, or aggravated beyond their natural progression by, his service-connected diabetes mellitus type II? The examiner must provide a fully-explained rationale for the opinions provided. In formulating the opinions, the examiner is to consider Dr. M.M.’s opinions dated in October 2015 and November 2019 as well as the excerpts from medical literature about the metabolic syndrome process and insulin resistance the Veteran provided in January 2016 and October 2019. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Telamour, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.