Citation Nr: 21003136 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 20-17 347 DATE: January 19, 2021 REMANDED Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from June 1965 to June 1969. His decorations include the National Defense Service Medal and the Vietnam Service Medal. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a November 2018 rating decision issued by a Department of Veterans Affairs (VA) Regional Office. Entitlement to service connection for hypertension is remanded. Although the Board sincerely regrets the additional delay, a remand is necessary to ensure that there is a complete record upon which to decide the Veteran’s claim and to afford him every possible consideration. The Veteran seeks to establish service connection for hypertension. He has asserted that his hypertension is secondary to his service-connected coronary artery disease with congestive heart failure. In a December 2020 Informal Hearing Presentation, the Veteran’s representative contended that the Veteran was entitled to service connection for hypertension as secondary to his service-connected adjustment disorder with depressive features. The representative also asserted that the Veteran should be service connected for hypertension on a direct theory, as due to the Veteran’s presumed exposure to herbicide agents in Vietnam. In support of the claim, the representative cited to a medical article purporting to show a relationship between hypertension and depression. See Rubio-Guerra, A. F., et al, (2013), Depression increases the risk for uncontrolled hypertension, Experimental and Clinical Cardiology, 18(1), 10–12. The representative also asserted that a study sponsored by VA concluded that Agent Orange exposure in Vietnam reveals a direct connection to hypertension. See National Academy of Sciences Report: Veterans and Agent Orange: Update 11 (2018). The Veteran underwent a VA examination in October 2018. The VA examiner noted a diagnosis of hypertension and opined that the Veteran’s hypertension was less likely than not proximately due or the result of the Veteran’s coronary artery disease. A subsequent addendum opinion clarified that the Veteran’s hypertension was less likely than not aggravated beyond its natural progression by coronary artery disease. See March 2020 addendum opinion. The examiner reasoned that while hypertension can lead to coronary artery disease, the reverse is not proven to be true. The examiner did not offer an opinion as to whether hypertension could be secondary to his acquired psychiatric disorder. An addendum opinion should be obtained to address the relationship between the Veteran’s hypertension and his acquired psychiatric disorder. Hypertension is not presumptively associated with herbicide exposure, including Agent Orange exposure. Although presumptive service connection cannot be granted for the Veteran’s hypertension, in addition to the presumptive regulations, a Veteran may establish service connection based on exposure to herbicide agents with proof of actual direct causation. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to herbicides does not preclude direct service connection for other conditions based on exposure to herbicides); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The examiner did not offer an opinion as to whether hypertension could be directly related to herbicide exposure in Vietnam. Therefore, the addendum opinion should also address the direct link between the Veteran’s hypertension and his conceded exposure to herbicides in Vietnam. This matter is REMANDED for the following action: 1. Ask the Veteran to identify, and provide appropriate releases for, any care providers who may possess new or additional evidence pertinent to the issue on appeal. If he provides the necessary release(s), assist him in obtaining the records identified, following the procedures set forth in 38 C.F.R. § 3.159. Any new or additional (i.e., non-duplicative) evidence received should be associated with the record. If any of the records sought are not available, the record should be annotated to reflect that fact and the Veteran and his representative should be notified. 2. Obtain copies of records pertaining to any VA treatment the Veteran has received since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record. 3. Arrange for the claims file to be reviewed by the VA examiner who prepared the October 2018 VA hypertension examination report (or a suitable substitute if that VA examiner is unavailable) for the purpose of preparing an addendum opinion. If the examiner finds that another examination of the Veteran is required, one should be undertaken. After reviewing the record, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the Veteran’s hypertension had its onset in, or is otherwise attributable to, his period of active service, to include his in-service exposure to herbicide agents (notwithstanding the fact that such an association may not be presumed under the law). If it is the examiner’s opinion that it is unlikely that the Veteran’s hypertension had its onset, or in otherwise directly attributable to service, the examiner should provide a further opinion as to whether it is at least as likely as not that the Veteran’s hypertension has been (a) caused or (b) aggravated (i.e., worsened beyond natural progression) by his service-connected psychiatric disorder. A complete medical rationale for all opinions expressed must be provided. If an opinion cannot be provided without resorting to speculation, the examiner should provide complete explanations of why this is so. In so doing, the examiner is requested to explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or the limits of current medical knowledge have been exhausted in providing an answer to that particular question. 4. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issue on appeal should be readjudicated based on the entirety of the evidence. If the benefit sought remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Joseph T. Leonard, Law Clerk 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.