Citation Nr: 20043682 Decision Date: 06/29/20 Archive Date: 06/29/20 DOCKET NO. 13-10 214 DATE: June 29, 2020 REMANDED Entitlement to service connection for hypertension, to include as due to service-connected coronary artery disease (CAD) and herbicide exposure is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1970 to September 1972, with service in Vietnam from September 1971 to September 1972. This case comes before the Board of Veterans’ Appeals (Board) on appeal of a January 2013 decision of the Regional Office (RO) of the Department of Veterans Affairs (VA). A February 2017 Board decision denied service connection for hypertension, to include as secondary to service-connected coronary artery disease (CAD). The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (CAVC), resulting in an October 2017 Joint Motion for Remand (JMR) by the parties. The October 2017 CAVC Order remanded the matter for compliance with the JMR instructions. This matter was previously before the Board in April 2018, when it was remanded for additional evidentiary development. In compliance with the remand directives, an addendum VA medical opinion was acquired. The directives have been substantially complied with, and the matter again is before the Board. D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to service connection for hypertension, to include as due to service-connected coronary artery disease (CAD) and herbicide exposure is remanded. Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2019). The Veteran contends that service connection is warranted for his hypertension as due to his herbicide agent exposure. VA has conceded that the Veteran has a current diagnosis of hypertension and that he was exposed to herbicide agents during his active service due to his service in Vietnam. The Veteran has also asserted entitlement to service connection for hypertension on a secondary basis, as due to his service-connected coronary artery disease (CAD). The Veteran was granted service connected for CAD in January 2013, rated as 60 percent disabling with an effective date of October 2011. See January 2013 rating decision. The Veteran was afforded a VA examination in December 2012 to determine the etiology of his hypertension, to include as due to service-connected CAD. The VA examiner opined that the Veteran’s hypertension is less likely than not caused by or a result of his CAD. The examiner noted that the Veteran had been treated for essential hypertension since the early 1980s. He also had a history of single vessel coronary artery bypass in 2011. Based on a review of medical literature, the VA examiner reasoned that hypertension is not caused by CAD, which was not known to exist in the Veteran at the time of the hypertensive diagnosis. The VA examiner further reasoned that the Veteran’s hypertension is of unknown etiology. No opinion was provided on whether or not the Veteran’s hypertension is aggravated by his service-connected CAD.   In accordance with the April 2018 Board remand, an addendum VA medical opinion was acquired in September 2019 to address the Veteran’s contention that his hypertension is related to herbicide exposure while stationed in Vietnam. The VA examiner noted the Veteran’s hypertension diagnosis in 1985. After reviewing the Veteran’s records and pertinent medical literature, the VA examiner opined that the Veteran’s hypertension is less likely than not related to his service, to include herbicide exposure. In support of this opinion, the VA examiner reasoned that a thorough review of the medical literature, including the National Library of Medicine, Mayo Clinic, American Heart Association, Center for Disease Control, and others, does not make any mention of herbicide exposure causing hypertension. The VA examiner instead pointed to the Veteran’s risk factors for developing hypertension, including strong family history of heart disease, diet, and hypercholesterolemia, that are well noted and proven in medical literature. No opinion was provided for any secondary connection to the Veteran’s service-connected CAD. Once VA undertakes the effort to provide a medical examination or opinion, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). Here, the Board finds that the September 2019 VA examination did not address the Veteran’s contentions of secondary service connection to his service-connected CAD at all and the December 2012 VA examination did not adequately discuss the potential aggravation of the Veteran’s hypertension due to his service-connected CAD. 38 C.F.R. § 3.310; see El-Amin v. Shinseki, 26 Vet. App. 136 (2013). Therefore, a remand is warranted to obtain an addendum opinion that adequately addresses the Veteran’s contentions that his hypertension is due to his service-connected CAD. The matters are REMANDED for the following action: 1. Return the record to the VA examiner who offered the September 2019 opinion regarding the etiology of the Veteran’s hypertension. The record and a copy of this Remand must be made available to the examiner. If the September 2019 VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The examination report must include a notation that this review of the evidence of record occurred. Upon determination of diagnostic impressions, if any, the examiner is asked to respond to the following inquiries: (a.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s current hypertension is caused by an in-service injury, event or disease, to include herbicide exposure? (b.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s hypertension (1) began during active service, (2) manifested within the applicable presumptive period after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? (c.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s hypertension was caused by his service-connected coronary artery disease? (d.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s hypertension was aggravated (permanently worsened beyond its natural progression) by his service-connected coronary artery disease? Review of the entire claims file is required. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts   and medical principles involved would be of considerable assistance to the Board. Attention is invited to the Veteran’s contentions that his hypertension is attributed to and has been aggravated by his service-connected coronary artery disease. 2. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran’s claim should be readjudicated. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for a response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999).   These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. C. Slaughter, 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.