Citation Nr: 21002915 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 14-29 403 DATE: January 19, 2021 REMANDED Entitlement to service connection for hepatitis B is remanded. Entitlement to service connection for hyperaldosteronism, to include as due to herbicide agent exposure is remanded. Entitlement to service connection for hypokalemia, to include as due to herbicide agent exposure is remanded. Entitlement to service connection for hypertension, to include as due to herbicide agent exposure is remanded. The propriety of a reduction of the disability rating for service-connected residuals of prostate cancer from 100 percent disabling to 40 percent, effective October 1, 2016, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from December 1970 to March 1972. These matters were previously before the Board in October 2017 at which time they were remanded for further evidentiary development. Although the Board regrets the additional delay, remand is again needed before the claims may be considered. See Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for hepatitis B is remanded. 2. Entitlement to service connection for hyperaldosteronism, to include as due to herbicide agent exposure is remanded. 3. Entitlement to service connection for hypokalemia, to include as due to herbicide agent exposure is remanded. 4. Entitlement to service connection for hypertension, to include as due to herbicide agent exposure is remanded. 5. The propriety of a reduction of the disability rating for service-connected residuals of prostate cancer from 100 percent disabling to 40 percent, effective October 1, 2016, is remanded. The October 2017 remand directed the Agency of Original Jurisdiction (AOJ) to provide the Veteran with the appropriate releases to obtain private treatment records and to associate such records with the claims file as it was previously indicated that relevant records were outstanding. The Veteran identified several private clinicians and submitted the appropriate releases in November 2020, December 2020 and January 2021. The AOJ contacted the identified providers and records from several clinicians were obtained and added to the claims file. However, records from one provider and possibly additional records from another provider covering the appeal periods for all claims on appeal were requested mere days before the Board’s review of the claims. As such records have not been associated with the claims file and there is no indication that they are unavailable, the Board finds that remand is needed to ensure such records are acquired before a decision may be rendered on the claims. The remand also directed the AOJ to obtain several new VA examinations in connection with the claims on appeal. The Board finds that new examinations are needed in order to ensure substantial compliance with the prior remand instructions. See Stegall, 11 Vet. App. 268. A VA examination regarding hepatitis B was requested with the examiner directed to consider the Veteran’s contention that his hepatitis B had its onset in service or was etiologically related to service, to include as a result of air gun vaccinations and sharing shaving utensils. The examiner was also asked to address multiple private treatment records indicating that the Veteran’s hepatitis B diagnosis dated back to the 1970s. An examination was conducted in June 2018. The examiner determined that the Veteran’s hepatitis B was less likely than not the result of active service. In support, he stated that there is no solid medical research to support the contention that air gun inoculation causes hepatitis B. If this claim were true, every veteran of the World War II, Korean, and Vietnam War eras would have hepatitis B. The Board finds that this opinion is not an adequate basis upon which to determine service connection. Although the examiner stated that there was no medical research to support the air gun inoculation contention, he did not discuss such findings in the context of the Veteran’s medical history, including indications that he was diagnosed as early as the 1970s. Further, the contention that hepatitis B was due to sharing shaving utensils was not addressed. As such, the Board finds that a new VA medical opinion is needed to address all contentions and medical evidence of record. A VA examination regarding hyperaldosteronism and hypokalemia was requested with the examiner directed to determine whether there were current diagnoses, including whether the conditions may have resolved during the appeal period (November 2013 to the present). Further, the examiner was requested to state whether hyperaldosteronism and hypokalemia were actual diagnosed disorders or merely laboratory findings. Finally, for each diagnosis, the examiner was asked to determine whether it was at least as likely as not that the conditions onset in service or was otherwise related to service, including due to herbicide agent exposure, or was caused or aggravated by a service-connected disability. An examination was conducted in June 2018. The examiner determined that the claimed hyperaldosteronism and hypokalemia were less likely than not the result of active service. In support, he stated that a review of the medical evidence revealed a diagnosis of hyperaldosteronism and associated hypokalemia dating back to September 22, 2013. Those conditions were corrected with medications. There was no research to support, the Veteran had not submitted any evidence, and the government had not conceded that exposure to Agent Orange causes hyperaldosteronism and hypokalemia. The Board notes that the examiner did not determine whether hyperaldosteronism and hypokalemia were actual diagnoses or merely laboratory findings and did not state when the conditions resolved. Further, the examiner did not discuss whether the conditions were caused or aggravated by service-connected disabilities, instead only stating that the conditions were not aggravated by Agent Orange exposure. Finally, as noted above, there out outstanding records covering the appeal period which may affect whether there are current diagnoses. As such, a new medical opinion is needed to consider all evidence of record and to adequately address all inquiries and theories of entitlement. A VA examination regarding hypertension was requested with the examiner asked to determine whether the Veteran’s hypertension had its onset in service or was otherwise etiologically related to service, including herbicide agent exposure. The examiner was asked to address the articles the Veteran submitted regarding a possible link between Agent Orange and hypertension. An examination was conducted in June 2018. The examiner determined that the claimed hypertension was less likely than not the result of active service. In support, he stated that a review of the medical evidence revealed a diagnosis of essential hypertension established in October 2008. Essential hypertension, also known as primary hypertension, is high blood pressure that does not have a known secondary cause. The diagnosis was made some 30 years after the Veteran’s exposure to herbicide agents and there was nothing in the medical documentation to support the Veteran’s assertion that such exposure caused his high blood pressure. Additionally, the government had not conceded hypertension as caused by exposure to Agent Orange. The Board notes that private treatment records reflected a current diagnosis of hypertension as early as March 2004. As such, the opinion is based on an inaccurate factual premise. Further, the examiner did not address the articles submitted by the Veteran suggesting a possible link between herbicide agent exposure and hypertension. Additionally, in a November 2020 informal hearing presentation, the Veteran’s representative contended that the Veteran’s hypertension is secondary to his service-connected diabetes mellitus type II. There are no medical opinions of record addressing a secondary theory of entitlement. As such, a new medical opinion is needed addressing all medical evidence of record and all theories of entitlement. The matters are REMANDED for the following action: 1. Attempt to obtain and associate with the claims file the identified medical records of treatment from Dr. Bressler from September 2015 to May 2020 and any outstanding records from Dr. Blair from September 2015 to November 2017. Document all attempts to acquire such records in the claims file. 2. Thereafter, obtain addendum medical opinions from appropriate VA clinicians to address the nature and etiology of the Veteran’s hepatitis B, hyperaldosteronism, hypertension, and hypokalemia. A review of the entire claims file should be conducted, and such review noted. Close attention should be paid to the inquiries below to avoid future remand. (a.) With regard to hepatitis B, the clinician should determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s hepatitis B had its onset in service or was otherwise etiologically related to service, including his claimed air gun vaccinations and sharing of shaving utensils. The examiner should address the multiple private treatment records and lay statements indicating that the Veteran’s hepatitis B diagnosis dates back to the 1970s. (b.) With regard to hyperaldosteronism and hypokalemia, the clinician should identify all current diagnoses that are manifested by findings of hyperaldosteronism and/or hypokalemia, including any that have resolved during the appeals period (November 2013 to the present) and identify when such conditions resolved. The clinician should also state whether hyperaldosteronism and/or hypokalemia are actual diagnosed disorders or merely laboratory findings. For each diagnosis, the clinician should state whether it is at least as likely as not (a 50 percent probability or greater) that such disability had its onset in service or was otherwise etiologically related to service, including exposure to herbicide agents. The clinician should also determine whether it is at least as likely as not (50 percent probability or greater) that hyperaldosteronism and/or hypokalemia was caused or aggravated (i.e., worsened beyond natural progression) by a service-connected disability. In determining whether the claimed condition is aggravated by any service-connected disability, discuss a baseline level of severity of the claimed condition established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity. (c.) With regard to hypertension, the clinician should determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s hypertension had its onset in service or was otherwise etiologically related to service, including exposure to herbicide agents. The clinician should specifically address the articles the Veteran has submitted regarding a possible link between Agent Orange and hypertension. The clinician should also determine whether it is at least as likely as not (50 percent probability or greater) that hypertension was caused or aggravated (i.e., worsened beyond natural progression) by service-connected diabetes mellitus type II. In determining whether the claimed condition is aggravated by any service-connected disability, discuss a baseline level of severity of the claimed condition established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity. (d.) In so rendering the opinions, the clinician is reminded that the fact that hyperaldosteronism, hypokalemia, and hypertension are not on the presumptive list of conditions due to herbicide agent exposure cannot by itself be the sole basis for a negative nexus opinion. Rather, the clinician should consider the Veteran’s specific military history, medical history, risk factors, and any other circumstances deemed relevant by the clinician in rendering an opinion. 3. A complete and fully explanatory rationale should be provided for any opinion. If any opinion cannot be rendered without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, by a deficiency in the record, or because the examiner does not have the needed knowledge or training. 4. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. Shereen M. Marcus Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Rachel E. Jensen, 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.