Citation Nr: 20005280 Decision Date: 01/23/20 Archive Date: 01/22/20 DOCKET NO. 17-54 794 DATE: January 23, 2020 REMANDED The issue of entitlement to service connection for hypertension, to include as due to herbicide agent exposure, or as secondary to service-connected disability, is remanded. The issue of entitlement to service connection for erectile dysfunction, to include as due to herbicide agent exposure, or as secondary to service-connected disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1967 to March 1969. These matters come before the Board of Veterans’ Appeals (Board) on appeal of a May 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In August 2019, the Veteran testified during a video conference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. 1. Entitlement to Service Connection for Hypertension The Veteran contends that he has hypertension that is directly related to his active service, or secondary to his service-connected disabilities. Specifically, the Veteran testified that his hypertension is due to exposure to herbicide agents during his active service, or secondary to his service-connected diabetes mellitus, type II. The evidence of record reflects that the Veteran has a current diagnosis of hypertension for which he is prescribed medications. See, e.g., November 2010 VA treatment record. Additionally, the Veteran is currently service-connected for diabetes mellitus, type II, due to his presumed exposure to herbicide agents. The Veteran’s service treatment records do not show a diagnosis of hypertension or include blood pressure readings consistent with hypertension. See 38 C.F.R. § 4.104, Diagnostic Code 7101 Note (1). However, the Veteran’s separation examination contains a blood pressure reading of 120/80. Such reading meets the criteria for prehypertension, which is defined as moderately increased blood pressure with systolic pressure of 120 to 139 or a diastolic pressure of 80 to 89. See Dorland’s Illustrated Medical Dictionary 1510 (32nd ed. 2012). The Veteran has not yet been provided a VA examination as to his claim for entitlement to service connection for hypertension. The Board finds that the low threshold for provision of a VA examination have been met in this case, as the record shows that the Veteran has a current diagnosis of hypertension, and the service treatment records show that the Veteran had elevated blood pressure readings consistent with prehypertension, suggesting that the current hypertension may have had its onset during his active service, or is otherwise associated with the Veteran’s service. Accordingly, the matter must be remanded so that the Veteran may be provided a VA examination to determine the likely etiology of the current hypertension and heart condition. Additionally, the Board notes that the Veteran is presumed to have been exposed to herbicide agents during his active service. The Board notes that the National Academy of Science (NAS) Institute of Medicine’s Veterans and Agent Orange: Update 11 (2018) upgraded hypertension from its previous classification in the category of “limited or suggestive” evidence of an association with exposure to Agent Orange to the category of “sufficient” evidence of an association. According to NAS, “[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. On remand, the VA examiner must address this update. During the August 2019 Board hearing, the Veteran testified that his hypertension may be secondary to his service-connected diabetes mellitus, type II. On remand, the VA examiner must address whether the Veteran’s hypertension is proximately due to, or aggravated beyond natural progression by, his diabetes mellitus, type II. 2. Entitlement to Service Connection for Erectile Dysfunction The Veteran seeks entitlement to service connection for erectile dysfunction. The Veteran was provided a VA examination as to his erectile dysfunction in December 2015. VA has a duty to ensure that any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board’s evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Here, the Board finds the December 2015 VA examination related to the Veteran’s erectile dysfunction is inadequate for decision-making purposes since the VA examiner did not provide an opinion as to whether the Veteran’s erectile dysfunction is directly related to his active service, or proximately due to or aggravated beyond natural progression by, his service-connected diabetes mellitus, type II. As the examination is not adequate for decision-making purposes, the Veteran must be provided a new VA examination to address whether the Veteran’s current erectile dysfunction is directly related to active service, to include his presumed exposure to herbicide agents, or secondary to his service-connected diabetes mellitus, type II. Additionally, the Board notes that the record for review may be incomplete. The most recent VA treatment records are from February 2019. VA treatment records, even if not in the claims file, are considered part of the record on appeal because they are within VA’s constructive possession. See 38 U.S.C. § 5103A; Bell v. Derwinski, 2 Vet. App. 611 (1992). On remand, updated VA treatment records must be obtained and associated with the record. The matters are REMANDED for the following action: 1. Obtain all outstanding treatment records relevant to the matters being remanded, to include from February 2019. 2. After the above, schedule the Veteran for a VA examination to determine the nature and etiology of his hypertension. Provide a copy of this remand and the record for the examiner to review. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner must address the following: (a.) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s hypertension is causally or etiologically related his active service, to include his presumed exposure to herbicide agents? Rationale must be provided for the opinion proffered. In rendering the requested rationale, the VA examiner should address the blood pressure readings in the prehypertension range contained in the Veteran’s service treatment records. Consideration should also be given to the National Academy of Sciences, Engineering, and Medicine’s (NAS) discussion of hypertension as an effect of Agent Orange exposure in Veterans and Agent Orange: Update 11 (2018), Washington, DC: The National Academies Press at pp. 487-498. The examiner must also note that the Veteran is not precluded from establishing service connection for hypertension with proof of direct causation. See Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). (b.) If not, whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s hypertension is proximately due to or the result of his service-connected disabilities, to include his service-connected diabetes mellitus, type II. Rationale must be provided for the opinion proffered. (c.) If not, whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s hypertension was aggravated beyond natural progression by his service-connected disabilities, to include his service-connected diabetes mellitus, type II. Rationale must be provided for the opinion proffered. 3. After the first remand directive, forward the record and a copy of this remand to the examiner who conducted the December 2015 VA examination, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. Following review of the record, the examiner should express an opinion as to: (a.) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s erectile dysfunction is causally or etiologically related his active service, to include his presumed exposure to herbicide agents? Rationale must be provided for the opinion proffered. The examiner must note that the Veteran is not precluded from establishing service connection for erectile dysfunction with proof of direct causation. See Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). (b.) If not, whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s erectile dysfunction is proximately due to or the result of his service-connected disabilities, to include his service-connected diabetes mellitus, type II. Rationale must be provided for the opinion proffered. (c.) If not, whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s erectile dysfunction was aggravated beyond natural progression by his service-connected disabilities, to include his service-connected diabetes mellitus, type II. Rationale must be provided for the opinion proffered. 4. After completion of the above, review the expanded record, including the evidence entered since the most recent statement of the case, and determine whether service connection for hypertension and/or erectile dysfunction may be granted. If any benefit sought remains denied, furnish the Veteran and his representative with a supplemental statement of the case. The appropriate period should be allowed for response before the appeal is returned to the Board. U. R. POWELL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. G. LeMoine 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.