Citation Nr: 20057550 Decision Date: 09/01/20 Archive Date: 09/01/20 DOCKET NO. 12-17 854 DATE: September 1, 2020 REMANDED Entitlement to service connection for a cardiovascular disability, to include hypertension, is remanded. REASONS FOR REMAND The Veteran had active duty service from March 1970 to December 1971. This matter comes before the Board of Veterans’ Appeals (Board) from a December 2011 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran’s claim was remanded by the Board in November 2019 in order to obtain new VA examinations addressing the nature and etiologies of his claimed for cardiovascular condition, to include hypertension. As discussed at greater length below, the Board does not find that its remand directives were substantially complied with relative to the March 2020 VA examinations now of record, and therefore, unfortunately, another remand is required. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board has recharacterized the issue on appeal given that the Veteran’s claim was expanded to include hypertension pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009). See September 2018 Board remand. 1. Entitlement to service connection for a cardiovascular disability, to include hypertension, is remanded. Upon review of the March 2020 VA examinations that were sought upon remand, the Board finds that the VA examiner did not indicate as to whether the Veteran has a currently diagnosed heart condition or has ever had a diagnosed heart condition. Additionally, relative to the Veteran’s direct service connection theory of entitlement for hypertension as due to herbicide exposure, the Board does not find that the VA examiner adequately addressed the same in stating that there is no VA nexus established between AO and hypertension. Here, the Board finds that the March 2020 VA examiner’s medical opinion speaks merely to presumptive service connection; however, the Veteran is not precluded from establishing service connection with proof of actual direct causation. See Combee v. Brown, 34 F.3d 1039, 1041-42 (Fed. Cir. 1994). Relative to the Board’s November 2019 remand, the Board does not find that the VA examiner adequately addressed the medical literature regarding the suggestive association between hypertension and herbicide exposure. Here, the Board again notes that updates from the National Academy of Sciences (NAS), in 2006 and 2008, concluded that there was "limited or suggestive evidence of an association" between hypertension and herbicide exposure. See 75 Fed. Reg. 32,540, 32,549 (June 8, 2010); 75 Fed. Reg. 81,332, 81,333 (December 27, 2010). In addition, hypertension was recently moved from the "limited or suggestive" category to the category of "sufficient" evidence of an association. See National Academies of Sciences, Engineering, and Medicine. 2018. Veterans and Agent Orange: Update 11 (2018). Thus, although the March 2020 VA examiner correctly alluded to the fact that the VA does not currently recognize/award service connection on a presumptive basis for hypertension as due to herbicide exposure, it remains unclear as to whether the aforementioned medical literature, that which is suggestive of a medical association between hypertension and herbicide exposure, was considered relative to the Veteran’s direct service connection theory of entitlement. Thus, the Board finds that another remand is required to ensure substantial compliance with its November 2019 remand directives. The matters are REMANDED for the following action: 1. Associate with the Veteran’s claims file any outstanding VA treatment records since March 2020. 2. Obtain addendum medical opinions for the Veteran’s claimed for cardiovascular and hypertension conditions. Upon review of the pertinent evidence of record, to include this remand, the VA examiner is requested to opine as to the following (if in-person VA examinations are deemed necessary to satisfy the Board’s request, schedule them): For the claimed for cardiovascular (heart) condition… a.) Does the Veteran have a diagnosis of a heart condition during the pendency of his claim? The Board emphasizes here that the March 2020 VA examiner did not indicate in the examination report whether the Veteran has a currently diagnosed heart condition, or that he has ever been diagnosed with a heart condition. b.) If, and only if, the VA examiner finds that the Veteran has a diagnosis of a heart condition during the pendency of his claim, opine as to whether it is at least as likely as not (50 percent probability or greater) that the diagnosed condition incurred during service, or is otherwise related to service, to include as due to the Veteran’s conceded exposure to herbicides. For the claimed for hypertension condition… c.) Is it at least as likely as not (50 percent probability or greater) that the Veteran’s diagnosed hypertension condition is medically related to his conceded exposure to herbicides during service? The VA examiner is requested to specifically consider the Veteran’s claim on a direct service connection theory of entitlement relative to conceded exposure to herbicides as well as the medical literature of record, identified by the Board as well as submitted in support of the claim by the Veteran, that is suggestive of a medical association between the hypertension and herbicide exposure, to include the National Academies of Sciences, Engineering, and Medicine 2018. Veterans & Agent Orange: Update 11 (2018). See also November 2019 Board remand. K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S.R. Fey, 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.