Citation Nr: 21003044 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 17-50 870 DATE: January 19, 2021 REMANDED Service connection for hypertension, to include as secondary to the service-connected coronary artery disease, is remanded. Service connection for a right knee disability is remanded. A total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1956 to February 1965, and December 1970 to April 1977 in the United States Army, with service in the Republic of Vietnam. His awards and decorations include two Purple Heart medals. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In May 2019, the Veteran and his spouse testified before the undersigned during a videoconference hearing. A transcript of the hearing is included in the electronic claims file. In August 2019, the Board remanded the above claims for further development. 1. Service connection for hypertension, to include as secondary to the service-connected coronary artery disease, is remanded. In August 2019, the Board remanded the claim for service connection for hypertension in order to obtain a VA medical opinion addressing direct service connection, including based on herbicide agent exposure, as well as secondary aggravation. While a VA examination was conducted in January 2020, the examination report does not substantially comply with the Board’s remand directives. Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141, 147 (1999) (requiring substantial compliance with Board remand directives). In the remand, the Board discussed that the National Academies of Sciences, Engineering and Medicine (NAS) recently found sufficient evidence of an association between hypertension and exposure to Agent Orange and other herbicide agents used during the Vietnam War. Veterans and Agent Orange: Update 11 (2018). Hypertension was upgraded from its previous classification in the category of “limited or suggestive” evidence of an association to the category of “sufficient” evidence of an association. The examiner was asked to consider the 2018 NAS update and address the matter of direct service connection based on herbicide agent exposure. The January 2020 examination report does not reflect that the examiner considered the NAS update and she made no mention of herbicide agent exposure in her opinion. As such, further remand is required. Additionally, on remand, the examiner must provide a full rationale on any opinion provided on the matter of secondary aggravation. While the January 2020 examiner opined that it is less likely than not that the Veteran’s hypertension has been aggravated by his service-connected coronary artery disease because there is no indication of this, she provided no further explanation or description of supportive evidence. 2. Service connection for a right knee disability is remanded. In August 2019, the Board remanded the claim for service connection for a right knee disability in order to obtain a VA medical opinion addressing direct service connection, including based on the Veteran’s extensive parachuting record. While his service treatment records (STRs) do not document a specific right knee disability, his service separation document shows his receipt of the Parachutist Badge, and his personnel file contains jump records documenting a large number of parachuting jumps. He testified at the hearing that he performed over 117 jumps during military service. A VA examination was conducted in January 2020. The examiner noted the lack of documentation of a right knee condition in service and provided a negative nexus opinion. She did not, however, explain why the Veteran’s extensive parachuting activities during service were less likely than not related to his current disability, notwithstanding the fact that the STRs do not show a specific a knee injury. Instead, she appeared to attribute the disability to the aging process, stating that aging can lead to a total knee replacement. When VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Stegall, 11 Vet. App. at 268. The Veteran is a combat veteran and reports right knee injuries related to parachuting activities, including parachuting in combat. See, e.g., May 2019 Statement in Support of Claim. As such, the examiner must accept the in-service incurrence of the Veteran’s combat-related right knee injuries. A further opinion, supported by a clear rationale, must thus be obtained for the claim. 3. A TDIU is remanded. Because a decision on the claims for service connection for hypertension and a right knee disability could significantly impact a decision on the issue of a TDIU, the issues are inextricably intertwined. A remand of the claim for a TDIU is required. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to obtain an opinion addressing the nature and etiology of his hypertension. A complete explanation should be provided for all opinions rendered. The following inquiries must be addressed: (A.) Whether it is at least as likely as not that the hypertension began during active service or is related to an in-service injury, event, or disease, including the Veteran's exposure to herbicide agents in Vietnam. In doing so, the examiner must address the 2018 NAS update which upgraded hypertension from its previous classification in the category of "limited or suggestive" evidence of an association, to the category of "sufficient" evidence of an association. According to NAS, "[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and herbicide agent exposure. (B.) Whether it is as least as likely as not that hypertension has been (i) caused OR (ii) aggravated (increase in disability) by the service-connected coronary artery disease. 2. Schedule the Veteran for a VA examination to obtain an opinion addressing the nature and etiology of his right knee disability. A complete explanation should be provided for all opinions rendered. The examiner must address whether it is at least as likely as not that the right knee disability began during active service or is related to an in-service injury, event, or disease, including his combat service and parachuting activities therein. In rendering this opinion, the examiner must consider the following: • The Veteran has been awarded two Purple Heart medals and reports that his right knee symptoms are related to combat service, including parachuting activities therein. As such, the examiner is directed to accept the in-service incurrence of the Veteran’s combat-related right knee injuries and thus, must accept as fact that these “injuries” occurred in service. • The Veteran was awarded the Parachutist Badge, and his personnel file contains jump records documenting a large number of parachuting jumps. He testified at the hearing that he performed over 117 jumps during military service. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Smith, 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.