Citation Nr: 20032464 Decision Date: 05/08/20 Archive Date: 05/08/20 DOCKET NO. 11-02 596 DATE: May 8, 2020 REMANDED Service connection for hypertension, to include as associated with exposure to herbicides in the Republic of Vietnam or as secondary to service-connected posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1970 to September 1971. His service included combat in the Republic of Vietnam. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. In September 2015 and September 2016 decisions, the Board remanded the claim for further development. The Board denied the Veteran’s claim in February 2019. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). In a February 2020 Joint Motion for Remand (JMR) decision, the Court vacated the Board’s decision and remanded the matter to the Board to obtain an adequate examination. Service connection for hypertension, to include as associated with exposure to herbicides in the Republic of Vietnam or as secondary to service-connected PTSD is remanded. The Veteran contends his current hypertension is due to in-service Agent Orange exposure or, alternatively, is secondary to his service-connected PTSD. The Board previously denied this claim in a February 2019 decision finding the most persuasive evidence of record did not support a nexus between hypertension and service or his PTSD. With regard to Agent Orange exposure, the Board noted recent NAS findings (the most recent Agent Orange update) indicative of “limited or suggestive” association between hypertension and herbicide exposure, but found such association was not conclusive in this Veteran’s specific case. Rather, according to a June 2018 VA examiner’s opinion and the examiner’s research into the relevant medical literature, a connection between Agent Orange exposure and the development of hypertension would only be possible within individuals in the Army Chemical Corps whom directly handled herbicides. Since the Veteran served as an M-113 armored personal carrier and not in the Army Chemical Corps, the June 2018 VA examiner found a nexus in this case unlikely. The Board denied the claim mainly relying on the June 2018 VA examiner’s opinion. The Board also denied service connection as secondary to PTSD finding the most persuasive evidence of record was against such an association. In so finding, the Board noted and weighed evidence submitted by the Veteran (to include evidence referenced by the Veteran in a March 2009 statement), to include internet copies of various medical literature and private medical opinion in support of a general existence of an association between PTSD and hypertension. The Board also noted consideration of the Veteran’s private doctor’s opinion, Bill Webb, D.O., but found the other evidence of record, to include the June 2018 VA examination, more persuasive. The February 2019 Board denial was vacated and remanded by virtue of a February 2020 JMR. Therein, the parties agreed that the June 2018 VA examination relied upon by the Board was inadequate. In particular, the parties agreed the matter was previously remanded in September 2015 and again in September 2016 for a VA examiner to specifically consider the 2012 NAS conclusion that found suggestive evidence of an association between herbicide exposure and hypertension notwithstanding that VA has not added hypertension to the list of conditions presumptively associated with Agent Orange exposure. In contrast, the June 2018 VA examiner noted review of the Journal of Occupational Environmental Medicine, but no specific mention or consideration of the NAS Agent Orange update. The examiner found a nexus between hypertension and Agent Orange exposure unlikely because “[e]xposure to herbicides is not presumptive for service connection.” While the examiner noted suggestive data of a connection between hypertension and Agent Orange exposure where a serviceman had more direct handling of herbicides, there is nothing in the VA examination report that indicates the examiner specifically considered the NAS Agent Orange update as directed in two prior Board remands. While the Board finds the June 2018 VA examiner’s opinion to be persuasive with an adequate rationale, the opinion was not directly responsive to the Board’s prior remands. Thus, in light of the February 2020 JMR and given that the Board’s prior remands specifically directed the examiner to consider the NAS Agent Orange update in rendering an opinion, a new VA medical opinion is warranted. See Stegall v. West, 11 Vet. App. 268, 271 (1998). It is also noted that the February 2020 JMR indicates the Board must provide an adequate statement of reasons or bases as to the weighing of the evidence, to include the evidence submitted by the Veteran in March 2009. In that regard, the JMR notes that the Veteran had previously written in correspondence to the VA that he felt his evidence was “totally ignored” by the RO. It is worth noting that the February 2019 Board decision specifically noted the evidence submitted by the Veteran in March 2009, to include medical literature and private medical opinions. To the extent the Veteran feels the RO has “totally ignored” this evidence, the RO is directed to consider the evidence in any subsequent adjudication rendered once development has been completed. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s hypertension is at least as likely as not related to in-service Agent Orange exposure specifically addressing and discussing the relevance of the 2012 conclusion of the National Academy of Sciences (NAS) that found “limited or suggestive evidence of an association” between herbicide exposure and hypertension (notwithstanding that VA has not added hypertension to the list of conditions for which presumptive service connection due to Agent Orange exposure is available under 38 C.F.R. § 3.309.) The examiner is directed to review the claims file and provide a complete rationale for all opinions provided. This would include a discussion of the pertinent evidence of record, to include the Veteran’s medical history, examination results, lay statements, as well as any additional medical or lay evidence relevant to the claim. 2. Thereafter, the AOJ must review the claims file to ensure that the foregoing requested development has been completed. In particular, review the requested medical opinion to ensure that it is responsive to and in compliance with the directives of this remand and if not, implement corrective procedures. See Stegall, 11 Vet. App. 268 (1998). Then, the AOJ should readjudicate the issue on appeal. The AOJ is specifically directed to consider and address the evidence submitted by the Veteran in March 2008 (and followed-up on in March 2009 correspondence), to include internet copies of various medical literature and private medical opinions regarding an association between PTSD and hypertension. If the benefit sought on appeal is not granted to the Veteran’s satisfaction, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded the requisite opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Gandhi, 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.