Citation Nr: 20008494 Decision Date: 01/31/20 Archive Date: 01/31/20 DOCKET NO. 19-21 887 DATE: January 31, 2020 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected coronary artery disease and as due to herbicide exposure, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from June 1971 to September 1976. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2018 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). Upon review, the Board finds that further development is needed prior to adjudication of the claims. The Veteran was afforded a VA examination in December 2017 in connection with his claim for service connection for hypertension. The VA examiner noted that he was diagnosed with hypertension in 2003, but opined that disorder was less likely than not related to his service-connected coronary artery disease (CAD). The VA examiner explained that CAD is not a risk factor for hypertension and that current medical literature is silent for any mechanism by which CAD may cause or aggravate hypertension. Nevertheless, the December 2017 VA examiner did not address whether the Veteran’s hypertension is directly related to his military service. The Veteran’s service personnel records document service in the Republic of Vietnam in 1972 and 1973; therefore, he is presumed to have been exposed to the herbicides in service. In a July 2019 VA Form 9 and a November 2019 brief, the Veteran and his representative asserted that there is a link between hypertension and herbicide exposure. Specifically, in the November 2019 brief, his representative noted that the National Academy of Sciences has indicated that there is sufficient evidence of an association between hypertension and herbicide exposure. Although hypertension is not on the list of diseases that VA has associated with herbicide exposure, the regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. §§ 3.303 (d), 3.309(e); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In other words, a presumption of service connection provided by law is not the sole method for showing causation in establishing a claim for service connection for disability due to herbicide exposure. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange). In August 2018, Dr. S.T. (initials used to protect privacy) listed ICD codes that he found were most likely caused by or a result of exposure to Agent Orange; however, he did not provide any rationale for that conclusion. Moreover, the December 2017 VA examiner only addressed the claim that hypertension is secondary to the Veteran’s service-connected coronary artery disease. Therefore, the Board finds that an additional VA medical opinion are needed to determine the etiology of the Veteran’s hypertension. The matters are REMANDED for the following action: 1. The agency of original jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all healthcare providers who have provided treatment for hypertension and coronary artery disease. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA treatment records, to include any records dated since February 2017. 2. After completing the foregoing development, the AOJ should refer the Veteran’s claims file to the December 2017 VA examiner, or if that examiner is unavailable, to another suitably qualified VA examiner for a clarifying opinion as to the etiology of the Veteran’s hypertension. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and lay statements. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should also note that the Veteran served in the Republic of Vietnam during the Vietnam Era. Thus, he is presumed to have been exposed to herbicide agents during service. The examiner should provide an opinion as to whether it is at least as likely as not that any current hypertension is causally or etiologically related to the Veteran’s military service, including herbicide exposure therein (notwithstanding the fact that it may not be a presumed association). In rendering this opinion, the examiner should consider the studies cited by the Veteran’s representative in a November 2019 brief. The examiner should also opine as to whether it is at least as likely as not that the Veteran’s hypertension was caused or aggravated by his service-connected coronary artery disease. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history,” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner of review. 3. After completing these actions, the AOJ should conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. J. Williams, 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.