Citation Nr: 20004817 Decision Date: 01/23/20 Archive Date: 01/21/20 DOCKET NO. 15-41 829 DATE: January 23, 2020 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for peripheral neuropathy of the bilateral upper extremities is remanded. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1959 to February 1961. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In January 2018, the Board remanded the claims for VA medical examinations and opinions. The Veteran seeks service connection for hypertension and for peripheral neuropathy of his hands and feet. Unfortunately, the Board finds further remand is required. Regarding hypertension, the previous Board decision directed for a VA opinion that considered blood pressure readings from the Veteran’s March 1959 entrance examination and the December 1960 separation examination. Though a VA examination was provided, there appears to have been a misunderstanding, as the readings the examiner attributed to the entrance and separation examinations do not match with those in the record. Moreover, the examiner’s negative nexus opinion was based on treatment records leading up to a formal diagnosis that “reflect[ed] acceptable blood pressures,” but the examiner’s rationale failed to discuss whether this negated years’ worth of earlier treatment records showing high blood pressure. Given this insufficient reasoning, the opinion is inadequate and a new one must be obtained. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Additionally, the Veteran contends that his hypertension is due to exposure to herbicide agents while serving in Korea. As the record does not reflect that full development has been conducted to attempt to confirm whether the Veteran served at the DMZ in an area in which herbicides are known to have been applied, the Board will direct for such development on remand. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). Regarding peripheral neuropathy of the upper and lower extremities, VA examiners in June 2018 and October 2019 offered negative nexus opinions, both noting that the Veteran had undergone chemotherapy, which also is associated with neuropathy. The Veteran has stated, however, that his neuropathy in the lower extremities was originally diagnosed as restless leg syndrome around 2000, when years of numbness and tingling in the hands and feet had worsened to the point that he went to the doctor for relief. He stated additionally that this diagnosis came “several years before the cancer.” Indeed, a December 1999 private treatment record shows a diagnosis of myoclonic disorder, for which he was seen by two doctors, and private cancer treatment records show that Veteran first underwent cancer treatment in November 2003. Because both VA examiners offered negative opinions dependent in part on the premise that the Veteran’s symptoms could have been caused by chemotherapy, the Board will remand for an opinion that considers the evidence showing that the Veteran’s neuropathic symptoms preceded his cancer treatment. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008); Reonal, 5 Vet. App. at 461 (1993); Barr, 21 Vet. App. at 311. Moreover, the Board will direct for attempts to obtain the records from the providers mentioned in the December 1999 record, as the private records may assist the Veteran in establishing his claim for service connection. 38 U.S.C. § 5103A(b); 38 C.F.R. § 3.159(c). The matters are REMANDED for the following action: 1. Undertake appropriate action to assist the Veteran in obtaining private treatment records from the offices of Dr Hudson and of Dr Pappert. 2. Request that the U.S. Army and Joint Services Records Research Center (JSRRC) take appropriate measures to verify the Veteran’s account of in-service herbicide exposure. The Veteran has stated that he served at a “remote outpost north of Mickey Mouse Corner, and up to the DMZ and at the 38th.” 3. Schedule the Veteran for an examination regarding hypertension. The examiner must opine on all of the following: (a)(i) Did the Veteran’s hypertension clearly and unmistakably exist before his entrance to service in March 1959? Consider and discuss that on the Veteran’s entrance medical examination the examiner recorded a blood pressure of 170/90 and then, after two hours and forty-five minutes at rest, 140/80. (a)(ii) If the Veteran’s hypertension did clearly and unmistakably preexist service, was the Veteran’s hypertension clearly and unmistakably NOT aggravated (permanently worsened beyond the natural course) during his service? (b) If either (a)(i) or (a)(ii) is answered in the negative, then answer all of the following: (b)(i) Is it at least as likely as not that the Veteran’s hypertension was incurred in service or within a year after his separation? (b)(ii) Assume for the sake of argument that the Veteran was exposed to herbicide agents. Is it at least as likely as not that the Veteran’s hypertension is related to his service, including his exposure to herbicide agents? (This question must be independently considered without regard to whether the Veteran’s hypertension was incurred within a year after separation.) The examiner should consider that the National Academy of Sciences recently upgraded 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 agent exposure. See Vietnam Veterans and Agent Orange Exposure New Report, November 2018. (It is not adequate to solely state that there is no connection because the condition is not currently listed among the presumed diseases linked to herbicide exposure.) (b)(iii) Assume for the sake of argument that the Veteran was NOT exposed to herbicide agents. Is it at least as likely as not that the Veteran’s hypertension is related to his service? In formulating these opinions under (b), consider and discuss that while in service in December 1960 the Veteran had a blood pressure reading of 126/80 and that on an exam five months after separation he had a reading of 124/76. All other evidence of record should be considered, including private treatment records from a Medical Clinic (uploaded into the record in May 2013) recording blood pressure from the years 1994 to 2003. 4. Obtain an opinion regarding peripheral neuropathy of the upper and lower extremities. Attempt to acquire the opinion from the October 2019 VA examiner; if that doctor is unavailable, attempt to acquire the opinion from the June 2018 VA examiner; if that clinician is unavailable, acquire the opinion from another clinician. The clinician must answer all of the following questions: (a) Is it at least as likely as not that the Veteran’s peripheral neuropathy in the upper extremities and/or lower extremities began in service or within a year after separation? (b) Assume for the sake of argument that the Veteran was exposed to herbicide agents. Is it at least as likely as not that the Veteran has been diagnosed as having early onset peripheral neuropathy in the upper extremities and/or lower extremities which manifested within one year of his last exposure to herbicides; and/or whether it is at least as likely as not that peripheral neuropathy in the upper extremities and/or lower extremities is related to exposure to temperatures as low as negative 40 degrees? (c) Assume for the sake of argument that the Veteran was NOT exposed to herbicide agents. Is it at least as likely as not that the Veteran’s peripheral neuropathy in the upper extremities and/or lower extremities is related to service, to include exposure to temperatures as low as negative 40 degrees? In formulating these opinions, the clinician should discuss the diagnosis of myoclonic disorder in December 1999, and the Veteran’s statement that he sought treatment at this time after existing symptoms had progressively worsened. 5. After the above development and any other development deemed necessary is completed, readjudicate the Veteran’s claims. K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Davis, 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.