Citation Nr: 21002603 Decision Date: 01/14/21 Archive Date: 01/14/21 DOCKET NO. 12-35 034 DATE: January 14, 2021 ORDER Service connection for a right shoulder disability is denied. Service connection for a left shoulder disability is denied. Service connection for a disability of the lumbar spine is denied. Service connection for a disability of the cervical spine is denied. Service connection for a right hip disability is denied. Service connection for a left hip disability is denied. Service connection for a right knee disability is denied. Service connection for a left knee disability is denied. Service connection for a disability of the right eye is denied. Service connection for a disability of the left eye is denied. Service connection for chronic obstructive pulmonary disease (COPD) or any pulmonary disability is denied. A compensable disability rating for bilateral hearing loss is denied. REMANDED The appeal for entitlement to service connection for hypertension is remanded. REFERRED The issue of new and material evidence to reopen a previously denied claim of service connection for a sinus disorder was raised by the record in June 2011, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Another issue recently raised by the record is entitlement to service connection for kidney disease, as a June 2019 VA examiner made reference to the Veteran’s diabetic renal disease. If the Veteran’s kidney disease was proximately caused or aggravated by his service-connected diabetes, then secondary service connection may be warranted. These matters are referred to the AOJ and to the Veteran and his representative for consideration. FINDINGS OF FACT 1. Disabilities of the right and left shoulders, lumbar and cervical spine, right and left hips, right and left knees were not initially manifest during service or within one year following service; no other connection to service is shown. 2. Ocular hypertension, age-related cataracts, and refractive error of the eyes were initially manifest during service, and no other connection to service is shown. 3. The Veteran does not have a COPD or any pulmonary disability which may be associated with military service in any way. 4. Audiometric testing revealed Level I, Level II, and Level III hearing acuity in throughout the appeal period. CONCLUSIONS OF LAW 1. The criteria for service connection for disabilities of the right and left shoulders, lumbar and cervical spine, right and left hips, and right and left knees have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. 2. The criteria service connection for ocular hypertension, age-related cataracts, and refractive error of the eyes have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 3. The criteria for service connection for COPD or any pulmonary disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. 4. The criteria for a compensable disability rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.10, 4.85. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1967 to September 1971. The Veteran presented sworn testimony in support of his appeal during a May 2016 Board hearing before the undersigned Veterans Law Judge. The Board remanded the matter in September 2016 and again in May 2018. Service Connection Generally, service connection may be granted for any disability resulting from injury suffered or disease contracted in line of duty, or for aggravation in service of a pre-existing injury or disease. 38 U.S.C. §§ 1110, 1131. Service connection may be established by demonstrating that the disability was first manifested during service and has continued since service to the present time or by showing that a disability which pre-existed service was aggravated during service. Service connection may be granted for any disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303. To establish a right to compensation for a present disability on a direct basis, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Veteran may benefit from a presumption of service connection based on a chronic disease, such as arthritis. 38 C.F.R. § 3.309(a). When a Veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and arthritis becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Even if a chronic disease is not shown within one year of discharge, service connection may be established by showing continuity of symptomatology. Continuity of symptomatology may be shown by demonstrating “(1) that a condition was ‘noted’ during service or any applicable presumption period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology.” Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); see also Davidson v. Shinseki, 581 F.3d 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board”). However, the Federal Circuit held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). There are no statutes specifically dealing with asbestos and service connection for asbestos-related diseases and the Secretary of VA has not promulgated any specific regulations. However, VA has acknowledged that a relationship exists between asbestos exposure and the development of certain diseases which may occur 10 to 45 years after exposure; including pleural effusion and fibrosis, pleural plaques, mesotheliomas of pleura and peritoneum, lung cancer, and cancers of the gastrointestinal tract, and interstitial pulmonary fibrosis, also known as asbestosis. In addition, an opinion by VA’s Office of General Counsel discusses the development of service connection claims based upon asbestos exposure. VAOPGCPREC 4-2000. Medical nexus evidence is required to establish a claim based on in-service asbestos exposure. Essentially, VA must determine whether service records demonstrate evidence of asbestos exposure during service; whether there was pre-service, post-service, occupational, or other asbestos exposure; and whether there is a relationship between asbestos exposure and the claimed disease. Regulations pertaining to herbicide exposure provide that if a Veteran served on active duty in Vietnam during the Vietnam era, the Veteran is presumed to have been exposed to Agent Orange or similar herbicides. 38 C.F.R. § 3.307. These regulations also stipulate the diseases, including some types of cancer, for which service connection may be presumed due to an association with exposure to herbicide agents. 38 C.F.R. §§ 3.307(a)(6), 3.309(e). Evidence which may be considered in rebuttal of service incurrence of a disease listed in Section 3.309 will be any evidence of a nature usually accepted as competent to indicate the time of existence or inception of disease, and medical judgment will be exercised in making determinations relative to the effect of intercurrent injury or disease. 38 C.F.R. § 3.307(d). In this case, the Veteran’s exposure to herbicides during the course of his duties on the flight line in Thailand has been conceded. Service connection for several diseases presumed to have been caused by herbicide exposure has already been granted, including for coronary artery disease, prostate cancer, and diabetes mellitus. Shoulders, lumbar spine, cervical spine, hips, knees The Veteran contends that stresses on his body during service contributed to his later development of arthritis and degenerative disease in his shoulders, lumbar spine, cervical spine, hips, and knees. In a September 2010 statement, the Veteran asserted he may have injured himself during a car accident when he was on leave during service. He stated that his cousin, who was driving the car, was killed during the accident, but that he did not realize he had injured himself at the time. He began to experience back and neck pain after discharge from service, however, and he believes his current disabilities can be traced at least in part to this accident. During the May 2016 hearing on appeal, he did not mention an automobile accident, but instead attributed his arthritis and orthopedic disabilities to stresses and strains during service. That the Veteran currently has degenerative disease in these areas is well-established in the evidence of record. What is not shown in the record, however, is any service event indicating inception or other relationship between the currently shown orthopedic disabilities and service. According to the report of the June 1971 general medical examination conducted upon the Veteran’s separation from service, his upper extremities, spine, lower extremities and musculoskeletal system were deemed to have been normal upon clinical examination. The Veteran made no complaints involving his spine, joints, or bones during the separation examination. His service treatment records do not contain a report of having been in an automobile accident at any point during service. Unfortunately, there are no medical records available reflecting the Veteran’s physical condition after service. The earliest records which were obtainable, following exhaustive efforts, are dated in 1994. A November 1994 private medical record contains a reference to a 1971 motor vehicle accident in which the Veteran’s left wrist was injured. There is no indication of any injury or complaint during service involving the Veteran’s shoulders, lumbar spine, cervical spine, hips or knees. Although the Veteran reports having had an automobile accident in 1971, it is unclear whether the accident occurred during service or after his September 1971 discharge. In any event, as the separation examination report showed normal orthopedics with no further references to injury in his service treatment records, and the 1994 reference to an automobile accident involved only the Veteran’s left wrist which is not at issue here; there is no basis for finding an injury to the Veteran’s shoulders, spine, hips, or knees, at that time. The Veteran was provided with VA examinations of these areas, in the attempt to identify a nexus to service. Without exception the resulting opinions were negative. A March 2017 VA orthopedic examiner declined to establish a nexus to service for the Veteran’s shoulders, knee, hip, and spine problems. In short, the preponderance of the evidence is against the Veteran’s claim for service connection for orthopedic disability involving the shoulders, lumbar spine, cervical spine, hips, and knees. No injury or disability of any kind involving these body parts is shown during service, or within one year of service. It appears that his orthopedic disabilities were initially manifested many years after service. No other connection to service is shown. Therefore, service connection is not warranted, on either a direct basis or as presumed under law to have been incurred during service. The benefit sought must be denied. Eye impairment The Veteran’s service treatment records do not reflect any complaints involving his eyes during service. His distant visual acuity was measured as 20/20 in both eyes during the September 1967 entrance examination. Upon separation, his uncorrected near and distant visual acuity was measured as 20/20 in both eyes. In a February 2013 statement, received by VA in May 2013, a doctor of osteopathy presented the opinion that the Veteran’s glaucoma was more likely than not caused by exposure to fuels and herbicides during his military service in Thailand. No rationale or explanation for this causal relationship was presented, however. During the May 2016 hearing, the Veteran linked his vision problems to his migraine headaches, noting that during a migraine episode, he experiences pain behind his eyes along with blurred vision. The Veteran was provided with a VA eye examination for purposes of compensation in December 2016. The examiner rendered diagnoses of diabetes without ocular manifestation, cataracts, ocular hypertension, and dry eyes. With regard to the ocular hypertension, the examiner explained that the Veteran had been diagnosed with glaucoma in 2011, but as he did not develop any glaucomatous visual field defect, the diagnosis was changed to ocular hypertension in 2016. Based upon review of the Veteran’s service treatment records and VA medical records together with the clinical examination, the examiner opined that there was no connection between any of the Veteran’s ocular diagnoses and service. Essentially, the examiner noted the absence of any incident involving the eyes during service and the length of time after service before the disabilities shown were initially manifested, to support the opinion. A July 2020 optometry note reflects a comprehensive eye examination. The resulting diagnoses were 1) ocular hypertension on treatment, 2) diabetes mellitus without retinopathy, 3) age-related cataracts, and 4) refractive error. The Veteran used two different types of eyedrops for control of ocular hypertension and used prescription glasses. Congenital or developmental defects and refractive error of the eye are not considered diseases or injuries within the meaning of applicable legislation. See 38 C.F.R. §§ 3.303(c), 4.9; Winn v. Brown, 8 Vet. App. 510, 516 (1996), and cases cited therein. However, refractive error due to injury or disease related to service may be service-connected; it is only refractive error which is congenital in nature which cannot be service-connected under the law. For diseases such as ocular hypertension and cataracts, service connection is appropriate when a connection to service is established. With regard to the Veteran’s contention that his eye problems are related to migraine headaches, for which service connection has been granted, the problems he related during the hearing, eye pain and blurriness, must be considered part and parcel of the headaches, as these symptoms appear when he is experiencing a headache. To this extent, the Veteran should argue for compensation for such symptoms by submitting an increased rating for headaches. With regard to the theory that glaucoma or the re-named ocular hypertension, is related to herbicide exposure or fuel exposure, we observe firstly that neither glaucoma nor ocular hypertension is a defined disease which may be presumed under law to have been caused by herbicide exposure. 38 C.F.R. § 3.309(e). Although a medical opinion has been presented in the attempt to prove direct causation, the opinion does not provide any explanation as to how exposure to fuels or herbicides would trigger the development of glaucoma many years later. Furthermore, subsequent opinion from an eye specialist indicated that an actual diagnosis of glaucoma was a misdiagnosis and was properly diagnosed as ocular hypertension. The Board gives this opinion greater probative weight as it is rendered by an eye specialist who explained that a diagnosis of glaucoma was incorrect as there has been no glaucomatous visual field defect. The doctor of osteopathy opinion does not speak to the cause of ocular hypertension and holds little probative weight. Lastly, the Board observes that if the Veteran were to develop diabetic retinopathy in the future, service connection as secondary to diabetes mellitus would likely be appropriate. It is fortunate that he has avoided any manifestations of this disease thus far, however. In sum, the preponderance of the evidence is against service connection for ocular hypertension on treatment, diabetes mellitus without retinopathy, age-related cataracts, and refractive error of the eyes, as no nexus to service is shown. COPD or other pulmonary disability The Veteran asserts service connection for COPD, or other pulmonary disease is warranted. He asserts that although he has a lengthy smoking history, dating back to service, exposure to airplane fuels, herbicides, and possibly asbestos during service contributed to his development of lung disease. The Veteran’s service treatment records do not reflect any pulmonary complaints during service, other than acute several episodes described as sinusitis, bronchitis, laryngitis. Upon the June 1971 separation examination, his lungs and chest were deemed clinically normal. A chest X-ray taken at that time was deemed to have been negative. Private X-ray studies in January 1997 and June 1999 were interpreted as negative. The lungs were clear and free of active infiltrates, with no pleural effusion or reaction present. A July 2009 chest X-ray was interpreted as showing clear lung fields bilaterally. The report of a December 2011 emergency room visit shows the Veteran reported with a cough, sore throat and nasal congestion. A chest X-ray was interpreted as showing COPD with right minimal infiltrates but no acute cardiopulmonary disease. The diagnostic assessment was of sinusitis and pharyngitis. The discharge instructions, however, reflect that the Veteran was treated for COPD. During a March 2012 VA pulmonary examination for purposes of compensation, the Veteran reported that he had had pneumonia during service, and that every year he gets the same type of infection in his lungs. The examiner reviewed the Veteran’s service treatment records and his VA treatment records in addition to performing a clinical examination of the Veteran. Such review included pulmonary function test results, which were interpreted as normal, chest X-rays which were interpreted as normal, and a review of the Veteran’s treatment records, which included antibiotic treatment for an acute respiratory infection. The examiner concluded that the Veteran did not have a chronic pulmonary diagnosis, to include chronic obstructive pulmonary disease. The examiner noted there was no radiographic or clinical evidence or abnormal pulmonary function testing supporting such a diagnosis. The examiner interpreted the report of “pneumonia” in service as indicating bronchitis, in today’s medical terminology, and noted that it “more likely than not healed without residual.” Most important to the examiner’s conclusion was that no chronic respiratory or pulmonary disease was identified during the examination. A February 2013 statement from a private doctor of osteopathy provides the opinion that the Veteran’s pulmonary disease is related to exposure to fuels and possible exposure to herbicides while he was stationed in Thailand. The statement does not identify the nature of the Veteran’s pulmonary disease, however. The same doctor presented a July 2016 medical opinion that the Veteran’s COPD was a result of asbestos exposure during military service. An August 2014 chest X-ray was interpreted as showing clear lung fields bilaterally. In 2015 the Veteran participated in a cardiology research study, which involved an extensive health work-up and subsequent monitoring. No pulmonary disability or disease was identified during any of the stages of the study. It was specifically noted that he had no COPD throughout the length of the study. During the May 2016 hearing on appeal, he testified that he believes that breathing jet fuels and gas during the course of his military duties as a fuel specialist in service contributed to his COPD. Although he acknowledged during the hearing that smoking contributed as well, he believes his military exposure worsened the problem. He also postulates that he was exposed to asbestos in insulation during service, that may have contributed to his current lung problems. The Veteran was provided with another VA examination in March 2017. This examiner also concluded that the Veteran did not have a pulmonary disease or findings, noting that there was no confirmed diagnosis of COPD in the Veteran’s medical records and that there were normal findings during the clinical examination. An addendum opinion dated the same month provides that the Veteran does not have any significant respiratory conditions, and by extrapolation, no asbestos-related lung disease. Congress has prohibited service connection for a Veteran's death or disability on the basis that it resulted from an injury or disease attributable to the use of tobacco products by a Veteran during active service. 38 U.S.C. § 1103. Thus, any lung disease which was caused by the use of tobacco cannot receive a grant of service connection. Upon careful review of the voluminous medical evidence, the Board can only conclude that the Veteran does not have a current diagnosis of COPD or other pulmonary disorder. Although his VA treatment records contain several references to COPD by history, there are no diagnostic workups showing COPD. Each time the matter was investigated, no diagnosis was rendered. The medical statements providing a diagnosis of COPD hold some probative value, but such probative value is greatly outweighed by VA examiner opinion based upon review of lay statements, clinical findings and radiographic results throughout the entire appeal period. The Board finds that diagnoses of COPD are misdiagnoses and such disorder has not been present for any time during the appeal period. Notably, one record noted treatment for COPD but reflected diagnostic assessments of sinusitis and pharyngitis – which are also not shown to be chronic disorders since service. Absent a chronic disability involving the Veteran’s lungs, service connection on any basis is not warranted. Thus, it follows that absent a pulmonary disability associated with asbestos exposure, service connection on that basis is not warranted. Similarly, absent a pulmonary disability associated with herbicide exposure, service connection on that basis is not warranted either. Increased rating—bilateral hearing loss Disability evaluations are assigned to reflect levels of current disability. The appropriate rating is determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Hearing loss ratings range from noncompensable to 100 percent based on organic impairment of hearing acuity, as measured by controlled speech discrimination tests in conjunction with average hearing thresholds determined by pure tone audiometric testing at frequencies of 1000, 2000, 3000 and 4000 cycles per second. “Pure tone threshold average” is the sum of the pure tone thresholds at 1000, 2000, 3000 and 4000 Hertz divided by four. This average is used in all cases (including those in § 4.86) to determine the Roman numeral designation for hearing impairment from Table VI or VIa. 38 C.F.R. § 4.85, Diagnostic Code 6100. The rating schedule establishes eleven auditory acuity levels, designated from Level I for essentially normal hearing acuity, through Level XI for profound deafness. 38 C.F.R. § 4.85. The horizontal rows in Table VI (in 38 C.F.R. § 4.85) represent nine categories of the percentage of discrimination based on the controlled speech discrimination test. The vertical columns in Table VI represent nine categories of decibel loss based on the pure tone audiometry test. The Roman numeral designation is located at the point where the percentage of speech discrimination and pure tone threshold average intersect. 38 C.F.R. §§ 4.85, 4.87. In addition, 38 C.F.R. § 4.86 applies to exceptional patterns of hearing impairment. Under its provisions, when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman Numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. When the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next higher numeral. 38 C.F.R. § 4.86. “(D)isability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered.” Lendenmann v. Principi, 3 Vet. App. 345 (1992). The Veteran underwent a VA audiological examination for purposes of compensation in April 2012. At that time, his pure tone thresholds, measured in decibels, and the Maryland CNC word recognition score were as follows: April 2012 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 15 20 45 55 34 92% LEFT 5 35 55 60 39 88% Calculating the Veteran’s VA hearing score utilizing Table VI at 38 C.F.R. § 4.85 yields a score of Roman Numeral I in the right ear, and Roman Numeral II in the left ear. The examiner rendered a diagnosis of sensorineural hearing loss in both ears and certified that the results were valid, and that use of the speech discrimination score was appropriate for the Veteran’s situation. The Veteran reported difficulty understanding speech in noisy situations and difficulty hearing women when they were not looking directly at him. He was not using hearing aids. During the May 2016 Board hearing, the Veteran testified that he was having trouble with conversations when background noise was present, as speech sounded garbled to him. Pursuant to the Board’s remand, the Veteran underwent another VA audiological examination for purposes of compensation in July 2020. At that time, his pure tone thresholds, measured in decibels, and the Maryland CNC word recognition score were as follows: July 2020 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 25 35 60 65 46 88% LEFT 30 65 65 75 59 84% Calculating the Veteran’s VA hearing score utilizing Table VI at 38 C.F.R. § 4.85 yields a score of Roman Numeral II in the right ear, and Roman Numeral III in the left ear. The examiner rendered a diagnosis of sensorineural hearing loss in both ears and certified that the results were valid, and that use of the speech discrimination score was appropriate for the Veteran’s situation. According to the Veteran’s VA treatment reports, he has been issued hearing aids, but does not wear them all the time. Review of these test results shows that the Veteran’s hearing acuity has decreased over the lengthy time period this appeal has been ongoing. However, his hearing acuity remained at a level warranting noncompensable disability rating over that time. Entering the resulting bilateral numeric designation of Level I for the right ear and Level II for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a zero percent disability rating under Diagnostic Code 6100. Similarly, designations of Level II and Level III also equates to a zero percent disability rating under Diagnostic Code 6100. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 is not shown at any point during the appeal period. Based on this analysis, a compensable rating for the Veteran’s bilateral hearing loss is not warranted. The Board expressly acknowledges its consideration of the lay evidence of record when adjudicating this claim, including the Veteran’s reports of difficulty hearing and comprehending in multiple life situations. The Veteran is competent to report difficulty with his hearing; however, disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The rating criteria contemplate speech reception thresholds and ability to hear spoken words on Maryland CNC testing. The functional impact that the Veteran describes, is contemplated by the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Veteran’s main complaint is reduced hearing acuity and clarity, which is what is contemplated in the rating assigned. See Rossy v. Shulkin, 29 Vet. App. 142, 145 (2017). REASONS FOR REMAND The appeal for entitlement to service connection for hypertension is remanded. Hypertension was not shown during service, as the Veteran’s blood pressure readings were within normal limits. It thus does not appear that service connection on a direct basis is warranted, as hypertension was not initially manifested on active duty. As explained above, there is no medical evidence reflecting the Veteran’s physical condition for many years after service. Thus, service connection on a presumptive basis as a chronic disability cannot be presumed under law. The earliest treatment records available for review indicate that hypertension was initially diagnosed and treated during the 1990s. As diabetes was diagnosed in 2011, it is unlikely that hypertension is secondary to diabetes. However, another theory of entitlement remains. In the most recent Board remand, the Board noted that although current VA regulations do not provide hypertension as a presumptive disability associated with herbicide exposure, several recent medical and scientific studies have identified a possible association between hypertension and herbicide exposure. Therefore, the Board remanded for a medical opinion by an appropriate expert regarding any such relationship for the Veteran’s hypertension. Since that time, the National Academy of Sciences (NAS) Institute of Medicine has upgraded hypertension from its previous classification in the category of “limited or suggestive” evidence of an association with exposure to herbicides to the category of “sufficient.” Although VA obtained a medical opinion in June 2019, review of the opinion indicates that the author did not appear to be familiar with the recent studies on this issue, and relied upon the absence of documentation in the Veteran’s VA treatment records regarding herbicides. Similar to the private medical opinion submitted, there is no rationale regarding the herbicide theory. Where the record before the Board is inadequate to render a fully informed decision, a remand to the RO is required in order to fulfill its statutory duty to assist the Veteran to develop the facts pertinent to the claim. Furthermore, the RO is required to fully complete the development ordered by the Board. Stegall v. West, 11 Vet. App. 268 (1998); Ascherl v. Brown, 4 Vet. App. 371, 377 (1993). Therefore, upon remand, another VA medical opinion should be obtained for review by adjudicators. (continued on the next page) This matter is REMANDED for the following action: Arrange for a VA medical opinion, by an appropriate expert to review the Veteran’s relevant medical records and render an informed opinion as to whether it is more, less, or equally likely (probability of 50percent or greater) that the Veteran’s hypertension was caused or aggravated by exposure to herbicides. A complete rationale for the opinion expressed should be fully explained. In offering such opinion, the examiner should specifically discuss the NAS Institute of Medicine's Veterans and Agent Orange: Update 11 (2018) that upgraded hypertension from its previous classification in the category of "limited or suggestive" evidence of an association with exposure to Agent Orange to the category of "sufficient" evidence of an association and any further relevant studies. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Heather J. Harter, 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.