Citation Nr: 21000419 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 11-28 368 DATE: January 5, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes, ischemic heart disease, and posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1969 to October 1970, to include service in the Republic of Vietnam. In November 2016, December 2017, and May 2019, the Board remanded the appeal for additional development. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes, ischemic heart disease, and PTSD The Veteran contends that he has hypertension related to active service or secondary to a service-connected disability. He has undergone several VA hypertension examinations during the appeal period and various opinions were obtained but considered inadequate. Most recently, in May 2019, the Board determined that the January 2018 opinion was also inadequate. The appeal was again remanded for additional information. In December 2019, the Veteran underwent another VA examination and an opinion was obtained. In August 2020, VA requested an addendum because the examiner did not specifically address a November 2008 statement from a VA physician or treatise evidence cited in the August 2016 and November 2017 informal hearing presentations as specifically directed. This was subsequently accomplished by another VA physician. Regarding the relationship between diabetes and hypertension, the December 2019 examiner stated that diabetes does not result in hypertension when it is well controlled as in the Veteran’s case, with no evidence of microvascular complications. The examiner also noted that the Veteran had normal urine microalbuminuria, which is usually the first objective evidence of such complications. The August 2020 addendum opinion also indicates there was no evidence of microvascular or renal disease. In September 2020, the Veteran submitted a copy of VA lab results from July 2020, which shows elevated microalbumin and an elevated microalbumin/creatinine ratio. Considering this, additional opinion is warranted. 38 C.F.R. § 3.159(c)(4). Updated VA medical records should also be obtained. 38 C.F.R. § 3.159(c)(2). In November 2020, the representative argued that the Board should remand the matter for another medical opinion as the evidence indicates the Veteran’s hypertension may be related to exposure to herbicide agents. The Veteran served in Vietnam and exposure to herbicide agents is presumed. 38 C.F.R. § 3.307(a)(6)(iii). Hypertension is not a disease presumptively associated with herbicide exposure. See 38 C.F.R. § 3.309(e). Notwithstanding the presumptive provisions, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has determined that the Veteran’s Dioxin and Radiation Exposure Compensation Standards Act does not preclude a claimant from establishing service connection with proof of actual direct causation. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). In November 2018, the National Academy of Sciences moved hypertension from the “limited or suggestive” to “sufficient” evidence category for association with herbicides. See Veterans and Agent Orange: Update 11 (2018). Thus, the Board agrees that an opinion is needed which addresses this theory of entitlement. The matter is REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from August 2020 to the present. 2. Return the December 2019 VA examination and August 2020 addendum for additional opinion. Additional examination is not required unless specifically requested by the examiner. The examiner is requested to address the following: (a) Review the July 2020 VA lab reports showing elevated microalbumin and elevated microalbumin/creatinine ratio and indicate if this changes the opinions provided as to whether the Veteran’s hypertension is at least as likely as not proximately due to or aggravated by service-connected diabetes. (b) Indicate whether the Veteran’s hypertension is at least as likely as not related to in-service exposure to herbicide agents. In making this determination, the examiner must consider and address the National Academy of Science’s Agent Orange: Update 11 (2018), which upgrades hypertension from the category of “limited or suggestive” evidence of an association with herbicide exposure to the category of “sufficient” evidence. The examiner is further advised that service connection for a disease can be established on a direct basis as related to Agent Orange and is not precluded solely because the disease is not listed as a presumptive condition associated with herbicide exposure. A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinions cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), or by a deficiency in the record (additional facts are required) or the examiner (does not have the needed knowledge or training). LAURA E. COLLINS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Carsten, 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.