Citation Nr: 20007141 Decision Date: 01/29/20 Archive Date: 01/28/20 DOCKET NO. 09-17 562 DATE: January 29, 2020 ORDER Entitlement to service connection for a low back disability is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for a right knee disability is denied. REMANDED Entitlement to service connection for hypertension, to include as secondary to herbicide agent exposure or to service-connected disabilities, is remanded. FINDINGS OF FACT 1. The Veteran’s low back disability is not etiologically related to his active military service. 2. The Veteran’s left knee disability is not etiologically related to his active military service. 3. The Veteran’s right knee disability is not etiologically related to his active military service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a low back disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § §§ 3.102, 3.303, 3.304. 2. The criteria for entitlement to service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § §§ 3.102, 3.303, 3.304. 3. The criteria for entitlement to service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from February 1966 to January 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions by the VA Regional Office in Oakland, California. Previously, the Board remanded these claims in April 2015 and May 2017 to allow for the scheduling of a hearing before the Board. Subsequently, the Veteran testified before the undersigned at a hearing in August 2017. A transcript of his testimony has been associated with the claims file. In a December 2017 Board decision, the Board reopened a claim for service connection for a low back disability, which had previously been denied in a May 1979 rating decision that became final. However, the Board did not reach the merits of the claim. Instead, the Board remanded the low back disability claim, as well as claims for service connection for a bilateral knee disability and hypertension, to the RO for further development. Thereafter, the RO issued an August 2019 Supplemental Statement of the Case denying service connection for these disabilities. The matter now returns to the Board. A careful review of the claims file shows that there has been substantial compliance with the Board’s remand directives with respect to the low back and bilateral knee disability claims. See Stegall v. West, 11 Vet. App. 268 (1998). For instance, a hearing was arranged for August 2017. Additionally, the RO took appropriate steps to obtain VA examinations in connection with these claims. As such, the RO has substantially complied with the Board’s multiple remand directives regarding the Veteran’s low back and bilateral knee disabilities. Compliance with the Board’s remand directives with respect to hypertension are discussed in more detail in the Remand portion of the decision. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303. A veteran seeking compensation under these provisions must establish three elements: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. §§ 3.310(a). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service-connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. §§ 3.310(b); Allen v. Brown, 7 Vet. App. 439, 448 (1995). Presumptive service connection may be granted for “chronic diseases” if the disease manifests to a compensable degree within service or within the presumptive period of one year after separation. 38 C.F.R. §§ 3.307(a)(3). Arthritis is categorized as a chronic disease. 38 U.S.C. § 1101; 38 C.F.R. §§ 3.309(a). For the showing of “chronic” disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Service connection may also be established under 38 C.F.R. §§ 3.303(b) where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may legitimately be questioned. The continuity of symptomatology provision of 38 C.F.R. §§ 3.303(b) has been interpreted as an alternative to service connection for the specific chronic diseases listed in 38 C.F.R. § § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. §§ 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. §§ 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of the positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Here, the Veteran asserts that he is entitled to service connection for a low back disability and a bilateral knee disability. He alleges that he incurred back and knee injuries following landmine explosions and after jumping out of helicopters while carrying heavy equipment, and that these injuries have persisted since his service. 1. Entitlement to service connection for a low back disability The record indicates he has a current diagnosis of lumbosacral strain with degenerative disc disease and degenerative joint. Moreover, the Veteran’s service treatment records reflect complaints of low back pain during his service. Despite this current diagnosis and in-service complaints of back pain, however, the preponderance of the evidence weighs against finding that his low back disability began during service or is otherwise related to an in-service injury, event, or disease. At the outset, the Board notes that in the May 1979 rating decision, the RO found that the Veteran’s low back disability pre-existed his military service. The Board is charged with independently reviewing the evidence and finds that he did not have a low back disability upon entry onto active duty. Every veteran who served in the active military, naval, or air service after December 31, 1946, is taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment, and was not aggravated by such service. 38 U.S.C. §§ 1111, 1137. Only those conditions recorded in examination reports can be considered as “noted,” 38 C.F.R. § 3.304(b), and a history of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions. 38 C.F.R. § 3.304(b)(1). If the presumption of soundness is not rebutted, the Veteran’s claim is one for service connection. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). To rebut the presumption of soundness for conditions not noted at entrance into service, VA must show by both clear and unmistakable (obvious and manifest) evidence that the disease or injury existed prior to service, and that the disease or injury was not aggravated by service. VAOPGCPREC 3-03 (July 16, 2003); 70 Fed. Reg. 23,027 (May 4, 2005); Wagner v. Principi¸ 370 F.3d at 1096. The Veteran’s December 1965 report of medical examination at induction indicates that an orthopedic consultation was received but does not make any note of a low back disability. In the Veteran’s report of medical history that was attached to his December 1965 induction examination, he reported a prior history of recurrent back pain. Additionally, in service treatment records include a history from the Veteran in which he reported that he wore a back brace for six months prior to his service. However, the record is otherwise silent for any suggestion that the Veteran’s low back disability was a pre-existing condition, and it is not noted on his induction examination. The Board finds that the Veteran’s statements reporting a history of back pain are not enough to overcome the presumption of soundness. Turning to the question of whether the Veteran’s low back disability arose in or is otherwise related to service, the Veteran’s service treatment records indicate that he complained of lumbosacral pain in April 1966 and was referred for an x-ray, which yielded negative results. He also complained of sciatic pain in June 1966 and was assessed with lumbosacral strain. Service treatment records also reflect that the Veteran complained of severe back pain in August 1966 and October 1966, although the reporting clinician noted that the Veteran had normal physical examination findings. In a January 1968 report of medical history, the Veteran endorsed recurrent back pain symptoms, but his January 1968 separation examination report did not indicate the presence of any low back disabilities. This suggests that the Veteran did not separate from the Army with a low back disability service. The Board notes that for combat veterans, as defined under 38 U.S.C. § 1154(b), lay evidence alone can establish the in-service element of service connection, if consistent with the circumstances, conditions, or hardships of such service, even if there is no official record. 38 C.F.R. § 3.304(d). This is commonly referred to as the “combat presumption.” 38 U.S.C. § 1154(b) does not establish service connection for a combat veteran, but rather aids him in relaxing the adjudicative evidentiary requirements for determining what happened in service. Clyburn v. West, 12 Vet. App. 296, 303 (1999). The Veteran’s service records reflect a military occupational specialty as an infantry crewman. His service records also confirm that he received the Combat Infantry Badge (CIB). As such, the Board accepts that the circumstances of the Veteran’s combat service involved jumping out of helicopters and riding in vehicles that were impacted by explosions from landmines. Nonetheless, the Board finds that the evidence of record does not show that his service duties caused a chronic low back disability or that his current low back disability is otherwise etiologically related to this part of his service. Indeed, the Veteran’s January 1968 separation examination shows normal findings with respect to his low back. Moreover, in 2009 the Department of the Army found that there was no evidence of combat injuries such that the Army could issue the Veteran a Purple Heart for his service in Vietnam. See November 2009 Department of the Army Memorandum (stating that, although the Veteran desired to obtain a Purple Heart for his service in Vietnam, a Purple Heart was not authorized absent official documentation reflecting medical treatment for injuries sustained as a direct result of enemy action). Furthermore, in the same memorandum, the Department of the Army found that there were no records awarding the Veteran a Bronze Star Medal for specific instances of meritorious or heroic conduct while acting against the enemy. The Board finds this evidence highly probative as to whether the Veteran sustained any low back injury during his service. Ultimately, the Veteran’s service treatment records and service personnel records do not suggest that he sustained a low back injury during his combat service. As such, the Board finds that the Veteran did not incur or develop a low back disability during his combat service or otherwise. In fact, post-service evidence of record indicates that the Veteran actually sustained his low back disability in a work-related injury following his service, and that this injury gave rise to a workers’ compensation claim. Medical records related to this claim do not indicate that he had any low back disability from his military service that pre-dated his work-related injury. The Board finds that this evidence weighs against a finding that the Veteran’s current low back disability was incurred during his service, or that his low back disability is causally related to his service. The record indicates that, following discharge from service, the first documented injury to the Veteran’s back occurred in August 1975 while he was working as a construction worker. Subsequently, in June 1977, the Veteran underwent back surgery to remove a herniated disc at L5. A workers’ compensation injury report reflects that the Veteran incurred this injury after he fell backwards and hit a log. The Veteran sought temporary disability benefits for this work-related accident. The Veteran was examined multiple times in connection with his work-related back injury. The impression on his workers’ compensation examination report was that the Veteran had acute back strain with sciatica in his left leg. See October 1975 Examination Report. In an October 1975 examination report, Dr. L.B. reported that x-rays showed no evidence of fracture in the Veteran’s lumbar spine, but that there was evidence of some kind of “discogenic problem” at the L5-S1 level on the left and functional overlay. Dr. L.B. also noted that he previously examined the Veteran in May and June 1974 before his work-related injury occurred. In May 1974, Dr. L.B. indicated, the Veteran was diagnosed with lumbosacral strain. Dr. D.B. explained that the pain in his thoracal lumbar region mainly occurred with “heavy work.” Dr. L.B. did not indicate that the Veteran’s low back pain dated back to his military service. This is significant, as it suggests that the Veteran did not complain of any low back pain following his service and that his post-service complaints of low back pain were instead related to his post-service occupation. In a November 1975 report from Dr. H.B. in connection with the Veteran’s workers’ compensation case, Dr. H.B. stated that the Veteran had “a little bit of back trouble in the past,” but he makes no references to his military service either. Instead, Dr. H.B. notes that the Veteran had a “vertebrae slip” approximately one and a half years prior, and that he was over this trouble in a few days. Dr. H.B. stated that this incident “has been about all [the back trouble in the past that] he has had.” The Veteran’s post-service VA treatment records reflect a long history of complaints about low back pain. Notably, in a March 2006 VA chronic pain consultation, the Veteran complained of low back pain, which he said started after a job injury that resulted in back surgery approximately 25 years ago. The Veteran was afforded a VA examination in August 2019, at which time he reported that he had experienced many problems with his low back since his service. He also reported having two back surgeries. The examiner, after reviewing his claims file, noted a diagnosis of lumbosacral strain with degenerative disc disease and degenerative joint disease. The August 2019 examiner opined that the Veteran’s low back disability was less likely than not incurred in or caused by the Veteran’s service. Although the Veteran was seen for “lumbar strain” in service on various occasions, the examiner opined that these complaints were acute in nature and that no ongoing back problems were noted on his separation examination. The VA examiner noted that six years after service, in 1974, the Veteran was seen by his doctor with complaints of low back pain. Ultimately, the examiner opined, there was no correlation between the Veteran’s duties or injuries during service and his current low back pain. Instead, the Veteran’s degenerative disc disease and degenerative joint disease were a normal result of aging, and likely aggravated by the Veteran’s history of work in the construction industry. The Veteran has also submitted medical opinions in connection with his claim for a low back disability. In a January 2010 letter from Dr. A.S., the Veteran’s endocrinologist, Dr. A.S. opined that the Veteran’s military experience contributed to his chronic back pain. Dr. A.S. indicated that he had reviewed the Veteran’s “reported combat history,” and stated that the Veteran would jump out of helicopters and ride in vehicles that passed over landmines. Dr. A.S. cited to the results of imaging studies that were performed in February 2006 and December 2008, which diagnosed degenerative disc disease of the lumbar spine. As such, Dr. A.S. concluded, it appeared more likely than not that the Veteran’s military experience contributed to his low back problems. In a separate January 2016 letter, Dr. A.S. reiterated that the Veteran’s low back condition was related to recurrent trauma from jumping out of helicopters and blast injuries while in Vietnam. Having considered the medical opinions of record, VA affords the greatest probative weight to the August 2019 VA examiner’s opinion. This opinion was rendered following a thorough review of the claims file and an in-person examination and is supported by a detailed rationale and the medical evidence of record. For instance, the VA examiner acknowledged the Veteran’s complaints of low back pain during service, but also indicated that these problems were acute given the normal examination findings upon separation in January 1968. Further, the VA examiner noted the Veteran’s history of work on construction sites and the six-year gap between the Veteran’s service and his complaints of low back pain to his doctor. Such a lapse of time is a factor for consideration in deciding a service-connected claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Ultimately, the Board finds that the August 2019 VA examiner’s medical opinion is supported by the competent medical evidence of record. Indeed, the Veteran’s post-service VA treatment records suggest that the Veteran’s low back disability is a result of his post-service back injury, as opposed to his military service. The Veteran himself has acknowledged that his current back pain began after his work-related accident in 1975. Notably, the Veteran’s medical records following his 1975 back injury are silent for any complaints of back pain related to his military service. Although his treating physicians noted complaints of back pain in 1974 in connection with heavy lifting, there is no discussion of recurrent back pain during his military service. These reports on the onset of his back pain are considered exceptionally trustworthy, as they were made for the purpose of medical diagnosis. See White v. Illinois, 502 U.S. 346, 356 (1992). The Board finds that these statements are thus highly probative evidence regarding the etiology of the Veteran’s low back pain. Moreover, the Board finds the August 2019 VA examiner’s opinion more persuasive than the January 2010 or January 2016 private opinions from Dr. A.S., the Veteran’s endocrinologist. Although Dr. A.S. reported to have reviewed the Veteran’s “combat history,” he did not indicate whether he had reviewed relevant evidence of record, such as the post-service medical records in connection with the August 1975 work-related back injury. An opinion which does not consider all the relevant evidence of record is inadequate. Moreover, although Dr. A.S. provided references to medical literature to support his opinions, he did not provide any rationale as to how the cited medical literature applied to the Veteran’s claim. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). As such, the probative value of Dr. A.S.’s opinions are significantly diminished. Furthermore, the Veteran’s belief that his service is directly related to his current low back disability, regardless of how sincerely held, does not equate to sufficient proof of service connection. As noted above, the Veteran has reported that he first began experiencing symptoms of back pain during service, and that he has sought treatment for them since service. Although the Veteran is certainly competent to report on factual matters of which he has first-hand knowledge, such as experiencing symptoms during or after service, he has not established that he has the appropriate medical training or expertise to offer a probative opinion on such a complex medical question. See Jandreau, 492 F.3d at 1372. In addition, the Board is not persuaded by the Veteran’s contentions today regarding continuity of any low back symptoms as they are inconsistent with the evidence above showing that he did not have a low back disability until a post-service injury. After a careful review of the claims file, including the relevant evidence discussed above, the Board finds that the preponderance of the evidence weighs against the Veteran’s claim of entitlement to service connection for a low back disability. Additionally, there is no probative evidence that the Veteran’s diagnosed lumbar degenerative disc disease manifested within one year of his discharge from service. Therefore, the presumptive provisions regarding chronic diseases are inapplicable. 38 U.S.C. § 1112; 38 C.F.R. § 3.307, 3.309. Likewise, x-ray evidence from service did not indicate the presence of any arthritis in the spine. Although the Veteran reported experiencing recurrent back pain upon separation from service, the Veteran’s statements regarding the onset of his low back pain have been inconsistent. Moreover, his statements that his back pain began following his August 1975 work-related accident indicate that there is an intercurrent cause for his back pain. Given the Veteran’s statements as noted above, there is a lack of credible evidence showing that the Veteran experienced symptoms of arthritis, manifested as low back pain, continuously since his service. See 38 C.F.R. § 3.303(b); Walker, 708 F.3d at 1331. 2. Entitlement to service connection for a left knee disability 3. Entitlement to service connection for a right knee disability The Board also finds that the preponderance of the evidence weighs against a finding of service connection for a bilateral knee disability. The Veteran has a current diagnosis of osteoarthritis in his knees. The central question for the Board is thus whether the Veteran’s knee disability had its onset in or is otherwise etiologically related to his active duty service. The Veteran’s service records are absent for any complaints, symptoms, or treatment for a bilateral knee disability. As discussed earlier, however, combat veterans may establish in-service incurrence of a disease or injury through satisfactory lay or other evidence that is consistent with the circumstances, conditions, or hardships of service, even in the absence of official record of such incurrence. See 38 U.S.C. § 1154(b). Although the so-called combat presumption can assist veterans in establishing the second element of the service connection test, in-service injury, veterans must still establish the other elements of service connection, namely a current disability and a medical nexus. See Reeves v. Shinseki, 682 F.3d 988, 998-99 (Fed. Cir. 2012); Libertine v. Brown, 9 Vet. App. 521, 522-23 (1996). The Board accepts that the circumstances of the Veteran’s service involved physically demanding tasks. Nevertheless, the weight of the evidence does not show that the Veteran’s current bilateral knee disability is etiologically related to these in-service events. Indeed, the Veteran’s January 1968 separation examination indicates normal findings with respect to the Veteran’s knees, and the Veteran did not endorse any complaints of knee pain. In an August 2019 VA examination in connection with his bilateral knee disability, the Veteran initially reported to the VA examiner that he did not recall when his knees began to bother him. Then, later in the examination, the Veteran reported that his knees began to hurt when he was in Vietnam, and that his bilateral knee pain has continued ever since. The VA examiner noted that the Veteran was diagnosed with osteoarthritis in his knees in March 2009, but ultimately opined that his condition was less likely than not incurred in or caused by service. The VA examiner indicated that the Veteran’s separation examination was absent for any complaints with respect to his knees, and that post-service treatment records were silent for complaints of knee pain until 2009, over 40 years after service. Instead, the VA examiner opined, the Veteran’s knee pain was likely the result of the normal aging process, as well as his work in the construction industry. The Veteran also submitted a January 2010 opinion from Dr. A.S., his endocrinologist, as to the etiology of his bilateral knee disability. As with his January 2010 opinion with respect to the Veteran’s claimed low back disability, Dr. A.S. opined that the Veteran’s bilateral knee disability was more likely than not related to his combat experience. Dr. A.S. cited to imaging studies performed in March 2009 on the Veteran’s knees, which diagnosed mild degenerative changes, and stated that the Veteran’s history of jumping out of helicopters and being near exploding mines caused chronic knee pain. Dr. A.S. provided no other rationale for his opinion. Once more, the Board finds that the August 2019 VA examiner’s medical opinion is more persuasive than Dr. A.S.’s opinion. First, Dr. A.S. failed to account for negative evidence in the record, such as the lack of symptoms of knee pain on the Veteran’s January 1968 separation examination, or the lack of treatment, without explanation, for 41 years that passed between his service and his treatment for knee pain. Moreover, Dr. A.S. failed to provide a sufficiently detailed rationale as to the etiology of the Veteran’s knee disability. As such, his opinion is entitled to little probative weight. Conversely, the August 2019 VA examiner reviewed the Veteran’s service treatment records and post-service treatment records, and his opinion is supported by the medical evidence of record. The Veteran’s inconsistent statements regarding the history of the disability renders them not credible. Ultimately, the Board finds that there is no probative evidence that establishes direct service connection for a bilateral knee disability. Additionally, there is no probative evidence that the Veteran’s diagnosed osteoarthritis in his knees manifested within one year of his discharge of service. As such, the presumptive provisions regarding chronic diseases do not apply here. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. Furthermore, given the lack of any probative evidence that the Veteran experienced symptoms of arthritis during his service, 38 C.F.R. § 3.303(b) does not apply either. Accordingly, the preponderance of the evidence is against the claim, which must be denied. REASONS FOR REMAND Entitlement to service connection for hypertension, to include as secondary to herbicide agent exposure or to service-connected disabilities The Board finds that the Veteran’s appeal on this issue must be remanded once more for additional development. The Veteran has contended that his hypertension is a result of exposure to herbicide agents during service. Alternatively, the Veteran has contended that his hypertension is secondary to his other service-connected disabilities, including diabetes mellitus, post-traumatic stress disorder (PTSD), and coronary artery disease. In prior, unrelated rating decisions, the Veteran’s exposure to herbicide agents has been conceded as a result of his service in the Republic of Vietnam. The medical evidence of record also confirms that the Veteran has a current diagnosis of hypertension. As part of its duties to assist a veteran who has filed a claim for benefits, VA may be required to provide a medical examination. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). If an examination report is inadequate or does not contain sufficient detail, the Board is required to return the report in a remand. See Bowling v. Principi, 15 Vet. App. 1, 12 (2001). A remand by the Board confers a right to compliance with the directives of that remand. Stegall, 11 Vet. App. at 268. The Veteran was afforded a VA examination for his hypertension in January 2010. However, this VA examination did not address whether the Veteran’s hypertension was aggravated by his service-connected disabilities. Pursuant to the Board’s December 2017 remand instructions, the RO obtained an August 2019 addendum opinion on his hypertension claim. In the August 2019 addendum opinion, the VA examiner opined that the Veteran’s hypertension was less likely than not incurred in or caused by an in-service injury, event, or illness. The VA examiner stated that 95 percent of hypertension is essential in nature without specific causes, and that hypertension was not on the list of diseases for which presumptive service connection may be granted following Agent Orange exposure. The VA examiner also noted that there was no direct cause and effect relationship between PTSD or diabetes and developing high blood pressure, and that no medical literature supported that having PTSD or diabetes permanently aggravated hypertension. The August 2019 VA examiner assessed whether the Veteran’s hypertension had been permanently worsened as a result of his service-connected disabilities. The Board notes, however, that a “permanent worsening” of a non-service-connected disability is not required to establish secondary service connection based on aggravation. Secondary service connection is instead warranted for “any incremental increase in disability—any additional impairment of earning capacity—in non-service-connected disabilities resulting from service-connected conditions...regardless of its permanence.” See Ward v. Wilkie, Nos. 16-2157, 17-1204, 2019 U.S. App. Vet. Claims LEXIS 994 (Vet. App. June 14, 2019) (citing Allen v. Brown, 7 Vet. App. 439, 448 (1995)). As such, the VA examiner’s opinion on whether the Veteran’s hypertension was aggravated by service-connected disabilities is inadequate. In the absence of an adequate opinion, the current record before the Board lacks competent evidence sufficient to determine the etiology of the Veteran’s hypertension. On remand, an addendum opinion must be obtained that adequately addresses the etiology of the Veteran’s hypertension. Stegall, 11 Vet. App. at 268. The Board also notes that while hypertension is not on the list of diseases presumptively associated with exposure to herbicide agents, the National Academy of Sciences (NAS) has found that there is “limited or suggestive evidence of an association between” hypertension and exposure to herbicide agents (such as Agent Orange) based on a recent statistical study. See Determinations Concerning Illnesses Discussed in NAS Report: Veterans and Agent Orange: Update 2012, 79 Fed. Reg. 20,308 (Apr. 11, 2014); see also 38 U.S.C. § § 1116(b). The category “limited or suggestive evidence of an association” means that the “evidence suggests an association between exposure to herbicides and the outcome, but a firm conclusion is limited because chance, bias, and confounding could not be ruled out with confidence.” Id. A more recent study by NAS released on November 15, 2018, indicates that “[t]he latest in a series of congressionally mandated biennial reviews of the evidence of health problems that may be linked to exposure to Agent Orange and other herbicides used during the Vietnam War found sufficient evidence of an association for hypertension.” NAS, Hypertension Upgraded in Latest Biennial Review of Research on Health Problems in Veterans That May Be Linked to Agent Orange Exposure During Vietnam War (Nov. 15, 2018), available at http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=25137 (last visited December 16, 2019). The August 2019 examiner stated that hypertension had not been added to the list of diseases for which presumptive service connection may be granted based on herbicide agent exposure. However, the August 2019 examiner did not address the widely available studies described above. As such, remand is also necessary to adequately address this recent evidence. Accordingly, this matter is REMANDED for the following action: 1. After obtaining any necessary authorization from the Veteran, obtain all outstanding VA treatment records and relevant private treatment records. 2. Thereafter, obtain an addendum opinion on the etiology of the Veteran’s hypertension. The examiner must review the Veteran’s claims file in its entirety, including a copy of this remand. Following a complete review of the evidence of record, the examiner is requested to opine as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s hypertension began during or is etiologically related to his active duty service, to include as due to herbicide agents. The examiner is requested to include a rationale for all opinions rendered, citing to supporting clinical data and medical literature as appropriate. The examiner is informed that an opinion based on the fact that a claimed disease is not on VA’s list of recognized diseases associated with herbicide agent exposure will be deemed inadequate. The examiner’s attention is drawn to the 2018 study provided by the National Academy of Sciences finding that “[t]he latest in a series of congressionally mandated biennial reviews of the evidence of health problems that may be linked to exposure to Agent Orange and other herbicides used during the Vietnam War found sufficient evidence of an association for hypertension.” See National Academy of Science, Hypertension Upgraded in Latest Biennial Review of Research on Health Problems in Veterans That May Be Linked to Agent Orange Exposure During Vietnam War (Nov. 15, 2018). If the examiner finds that the Veteran’s hypertension did not begin or is not etiologically related to his service, the examiner is asked to opine as to whether it is at least as likely as not (50 percent probability or greater) the Veteran’s service-connected disabilities either (a) caused, or (b) aggravated the Veteran’s hypertension. These service-connected disabilities include post-traumatic stress disorder, diabetes mellitus, and coronary artery disease. “Aggravation” is defined as worsening beyond the natural progression of the disability. If the Veteran’s hypertension is aggravated by his service-connected disability(ies), to the extent possible, the examiner is requested to provide an opinion as to the approximate baseline level of severity of his hypertension before the onset of aggravation. If the examiner is unable to provide any requested opinion without resorting to speculation, he or she must indicate why this is so. Specifically, the examiner must indicate whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). If the reason for speculation is that the particular examiner does not possess the expertise, another examiner who does must provide the opinion in question. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Rademacher, 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.