Citation Nr: 21002674 Decision Date: 01/14/21 Archive Date: 01/14/21 DOCKET NO. 14-30 675 DATE: January 14, 2021 REMANDED Entitlement to service connection for hypertension, to include as due to presumed exposure to herbicides and/or secondary to service-connected posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served in the California Army National Guard and was ordered to active duty for training (ACDUTRA) from February 1965 to July 1965. He served on active duty from May 1968 to December 1969, including service in the Republic of Vietnam. This matter is before the Board of Veterans’ Appeals (Board) on appeal from the May 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In May 2018, the Board remanded the issues of entitlement to service connection for bilateral hearing loss, tinnitus, and hypertension, to include as secondary to service-connected PTSD. With regards to the hypertension claim, the Board remanded for an addendum opinion as to whether the Veteran’s hypertension is related to service or service- connected PTSD. In February 2020, the Board denied entitlement to service connection for bilateral hearing loss and granted service connection for tinnitus. The Board remanded the remaining issue of entitlement to service connection for hypertension. 1. Entitlement to service connection for hypertension, to include as due to presumed exposure to herbicides and/or secondary to service-connected posttraumatic stress disorder (PTSD) is remanded. Unfortunately, remand is necessary to properly adjudicate the issue on appeal. Although the Board regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide this claim so that the Veteran is afforded every possible consideration. The Veteran contends that his current hypertension is related to his active duty service. The Veteran has asserted that his hypertension was caused by the salt tablets he was required to take during his tour of duty in Vietnam from February 1969 to November 1969 and subsequently aggravated by his service-connected PTSD. The Veteran has expressed that he has no familiar history of hypertension. In addition, the Veteran served on active duty in the Republic of Vietnam and is therefore presumed to have been exposed to herbicide agents, including Agent Orange. 38 U.S.C. § 1116 (f); 38C.F.R. §3.307. The Veteran was afforded a VA examination in October 2019. The examiner stated that the Veteran’s medical records support that any currently diagnosed condition related to the Veteran’s claimed hypertension, is less likely than not incurred in or caused by a specific in-service illness, event, or injury, to include taking salt tablets during service in Vietnam, or manifested to a compensable degree within a year of separation from service. The examiner expressed that considering the history related by the Veteran, current examination findings, and medical record review, the currently claimed hypertension is less likely than not incurred in service. The examiner noted that the Veteran’s enlistment examination, service records, and separation examinations were all silent for hypertension. The examiner noted that the Veteran’s blood pressure became elevated around 1974 and 1975. Thus, the examiner stated that based on the Veteran’s medical records, the currently claimed hypertension is not incurred in service. The examiner also opined that the Veteran’s hypertension is less likely than not proximately due to or the result of the Veteran’s service-connected PTSD. The examiner stated that considering the history related by the Veteran, current examination findings and medical record review, the currently claimed hypertension is less likely than not due to his PTSD. The examiner stated that PTSD is not a known cause of hypertension. With regards to aggravation, the examiner stated that hypertension was less likely than not aggravated beyond its natural progression by the Veteran’s service-connected PTSD. The examiner stated that medical records did not demonstrate worsening of his hypertension over time. The examiner stated that the Veteran has been on the same medications for hypertension since 2010 and his blood pressure readings remained stable. In February 2020, the Board remanded the issue on appeal in order to obtain an addendum opinion to determine the onset and/or etiology of the Veteran’s hypertension, to include as due to presumed exposure to herbicides. In addition, the Board directed the examiner to consider that the National Academy of Sciences recently upgraded hypertension to the “sufficient” category from “limited or suggestive,” indicating that “there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. The Veteran was afforded a VA medical opinion in March 2020. The examiner opined that it was less likely than not that the Veteran’s hypertension incurred in or was caused by the claimed in-service injury, event, or illness. The examiner stated that there were no hypertension numbers or diagnosis in service. The examiner expressed that that the onset of hypertension began after discharge, in 1974. The examiner stated that the Veteran’s military occupational specialty (MOS) is notable for not being in Chemical Corps and that “VBA presumptive is not for hypertension in General Army Veterans but only for some Chemical Corps.” The examiner expressed that searching UPTODATE literature, has shown a consensus of a negative nexus at this time for the specifics for this Veteran. The Board finds that the March 2020 VA examiner’s opinion provided little rationale and is inadequate for purposes of determining service connection. First, the Board noted that a lack of a diagnosed hypertension disability in service cannot serve as the sole basis for a negative finding. Here, the examiner specifically relied on the fact that there was no hypertension numbers or diagnosis in service and thus the examiner provided a negative nexus. Second, the Board specifically stated that the examiner MUST consider the Veteran’s lay contentions in making the determination as to whether a nexus exists. Here, the examiner failed to address the Veteran’s lay contention that he was required to take two salt tablets daily in service and that he has no familiar history of hypertension. Finally, the Board also notes that service connection for a disability claimed as due to herbicide exposure may also be established by showing that a disability is, in fact, causally linked to such exposure. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Although the examiner stated that “VBA presumptive is not for hypertension in General Army Veterans but only for some Chemical Corps,” the examiner failed to provide rationale as to why the presumption of hypertension is not for General Army Veterans. It is unclear as to whether the examiner has considered the Veteran’s presumed herbicide exposure or strictly refuting the presumed exposure of herbicides in all General Army Veterans. Thus, a remand is necessary to provide the Veteran a more adequate examination. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Obtain an addendum opinion from a qualified VA medical professional regarding the nature and etiology of the Veteran’s hypertension. If the examiner deems that a full VA examination is required, schedule the Veteran for a full VA hypertension examination. The claims file and a copy of this Remand must be made available to and reviewed by the examiner in conjunction with the VA examination. Specifically, the examiner must opine as to whether it is as likely as not (a 50 percent probability or greater) that the Veteran’s hypertension is related to his active service, including his presumed exposure to herbicides in Vietnam. In rendering this particular opinion, the examiner must specifically discuss whether it is at least as likely as not that the Veteran’s hypertension was due to the salt tablets the Veteran was required to take during his tour of duty in Vietnam. The examiner should consider the Veteran’s statement that he has no familiar history of hypertension. In relation to whether the Veteran’s hypertension is related to his presumed exposure to herbicides in Vietnam, the examiner shoulder consider and discuss all relevant evidence of record including the National Academy of Sciences update to the report “Veterans and Agent Orange” wherein hypertension was upgraded from its previous classification in the category of “limited or suggestive” evidence of an association to herbicide agents, to the category of “sufficient” evidence of an association to herbicide agents. This applies to the Veteran as he was presumed exposed to herbicide agents due to his verified service in Vietnam. The Board points out that prior examiners reference to the “VBA presumptive is not for hypertension in General Army Veterans but only for some Chemical Corps” as the basis for the negative opinion is not adequate. Service connection for hypertension may be established by showing it is, in fact, causally linked to such herbicide exposure. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The examiner should note that the lack of a diagnosed hypertension disability in service cannot serve as the sole basis for a negative finding. Lay contentions must be considered and weighed in making the determination as to whether a nexus exists. A full and detailed rationale for all opinions, with citation to relevant medical findings or medical authority, would be helpful to the Board. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.D. 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.