Citation Nr: 21003373 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 19-00 506A DATE: January 21, 2021 ORDER The application to reopen the previously denied claim for entitlement to service connection for diabetes mellitus, Type II is granted. Service connection for diabetes mellitus, Type II is granted. Entitlement to service connection for left lower extremity neuropathy is denied. Entitlement to service connection for left upper extremity neuropathy is denied. Entitlement to service connection for right lower extremity neuropathy is denied. Entitlement to service connection for right upper extremity neuropathy is denied. Entitlement to service connection for sleep apnea is denied. Entitlement to service connection for pressure in eyes is denied. REMANDED Entitlement to service connection for hypertension is remanded. FINDINGS OF FACT 1. In a January 2010 rating decision, the RO disallowed the Veteran’s claim of entitlement to service connection for diabetes mellitus; the Veteran did not timely initiate an appeal of that decision within one year of notification. 2. The evidence received since the January 2010 rating decision relates to an unestablished fact necessary to substantiate the claim for diabetes mellitus. 3. The evidence is at least evenly balanced as to whether the Veteran was exposed to herbicide agents during his period of service at U-Tapao Royal Thai Airbase. 4. The Veteran has a current diagnosis of diabetes mellitus, Type II. 5. The Veteran does not have a current diagnosis of left lower extremity neuropathy related to active service. 6. The Veteran does not have a current diagnosis of left upper extremity neuropathy related to active service. 7. The Veteran does not have a current diagnosis of right lower extremity neuropathy related to active service. 8. The Veteran does not have a current diagnosis of right upper extremity neuropathy related to active service. 9. The Veteran’s diagnosed sleep apnea did not have its onset during active service, and it is not otherwise related to active service. 10. The Veteran’s claimed pressure in his eyes did not have its onset during active service, and it is not otherwise related to active service. CONCLUSIONS OF LAW 1. The January 2010 rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. The evidence received since the January 2010 rating decision is new and material and sufficient to reopen the claim of service connection for diabetes mellitus, Type II. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for diabetes mellitus, Type II have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for entitlement to service connection for left lower extremity neuropathy have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 5. The criteria for entitlement to service connection for left upper extremity neuropathy have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 6. The criteria for entitlement to service connection for right lower extremity neuropathy have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 7. The criteria for entitlement to service connection for right upper extremity neuropathy have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 8. The criteria for entitlement to service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 9. The criteria for entitlement to service connection for pressure in eyes have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1963 to May 1967, including service at U-Tapao Royal Thai Air Force base in Thailand. This case is before the Board of Veterans’ Appeals (Board) on appeal from an April 2017 rating decision. The Board previously issued a decision on this case on August 27, 2019; however, the decision preceded the Board’s response to an August 22, 2019 motion for an extension of time to submit additional evidence and argument from the Veteran’s attorney. Accordingly, the Board vacated the August 27, 2019 decision on October 24, 2019. On December 11, 2019, the Board, finding good cause for a 90-day extension of time, granted the motion of an extension request, allowing the Veteran or his attorney to submit additional materials within 90 days of the December 11, 2019 correspondence. On March 26, 2020, the Board issued a decision on this case; however, the decision preceded receipt of additional evidence submitted by the Veteran on March 18, 2020. Accordingly, the Board vacated the March 26, 2020 decision on July 24, 2020. New and Material Request to Reopen Generally, a claim which has been denied in an unappealed AOJ decision is final and may not thereafter be reopened and allowed. 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1100. Once the AOJ makes a determination as to a claim, it must mail to the claimant, and his or her representative if there is one, proper notice of the decision, including notice of the claimant’s procedural due process and appellate rights. 38 U.S.C. § 7105(b)(1); 38 C.F.R. § § 3.103(b)(1), 19.25, 20.1103. An appeal of an AOJ decision to the Board is initiated by the filing of a notice of disagreement (NOD) with the decision. 38 U.S.C. § 7105(a); 38 C.F.R. § 20.200. If a timely NOD is not filed, the determination becomes final and the claim will not thereafter be reopened or allowed, except as may otherwise be provided by regulations not inconsistent with Title 38 of the U.S. Code. 38 U.S.C. § 7105(c). Likewise, if the Veteran does not timely perfect an appeal to the Board following the RO’s issuance of a Statement of the Case (SOC), the rating decision on which the SOC is based becomes final. The exception to this rule of not reviewing the merits of a finally denied claim is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. The regulation that implements 38 U.S.C. § 5108 defines “new and material evidence” as evidence not previously submitted to agency decision makers which is neither cumulative nor redundant of evidence previously of record, and which by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim, and which raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). New evidence means existing evidence not previously submitted to agency decision makers. 38 C.F.R. § 3.156(a). Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence can be neither cumulative nor redundant of the evidence already of record and must raise a reasonable possibility of substantiating the claim. Id. Of note, under 38 C.F.R. § 3.156(b), “new and material” evidence received prior to the expiration of the appeal period will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. If VA receives new evidence within the appeal period of an AOJ decision, it must make a determination as to whether the evidence is new and material and if it does not do so then the claim does not become final but rather it remains pending. See Beraud v. McDonald, 766 F.3d 1402, 1406-07 (Fed. Cir. 2014). In determining whether evidence is “new and material,” the credibility of the evidence in question must be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). New and material evidence is required to reopen a final claim. See 38 U.S.C. § 5108; Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); 38 C.F.R. § 3.156. The Board has a jurisdictional responsibility to consider whether it was proper for a claim to be reopened, regardless of whether the RO granted or denied an application to reopen. See Jackson, 265 F.3d 1366, 1369. 1. Whether new and material evidence has been received sufficient to reopen a previously denied claim of service connection for diabetes mellitus, Type II New and material evidence has been received sufficient to reopen a claim of service connection for diabetes mellitus, Type II. Prior to the filing of the current claim of entitlement to service connection for diabetes mellitus, Type II, the AOJ denied this claim in a January 2010 rating decision. In the January 2010 rating decision, the Veteran was denied service connection for diabetes mellitus on the basis that the evidence failed to show that the Veteran was exposed to herbicide agents during active service. The Veteran received notification of this decision in January 2010. The Veteran did not submit a notice of disagreement (NOD). The Board finds that the Veteran did not timely appeal this decision within a year of notification, and the January 2010 decision became final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.1103. In the April 2017 rating decision, the RO continued the denial of the Veteran’s claim for service connection for diabetes mellitus because the evidence submitted was not new and material. The Veteran timely appealed the April 2017 decision with a December 2017 NOD. The RO issued a Statement of the Case (SOC) in December 2018, and the Veteran’s VA Form 9, substantive appeal to the Board was received in January 2019. Evidence received since the January 2010 rating decision includes VA treatment records, duplicate copies of service treatment records (STRs), lay statements, research studies, reports, and previous Board decisions regarding exposure to herbicide agents in Thailand. This evidence provides bases for reopening the claim for service connection. Specifically, the reports and lay statements recently submitted were not of record prior to March 2020, and it is not duplicative or cumulative of evidence previously of record. Moreover, the new evidence submitted is material in that it relates to the basis for the prior denial, the lack of evidence establishing a nexus, namely exposure to herbicide agents during service in Thailand. As such, the requirements for reopening the claim have been met. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). “To establish a right to compensation for a present disability, 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”- the so-called “nexus” requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases may also be established based upon a legal “presumption” by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected condition. 38 C.F.R. § 3.310. 2. Entitlement to service connection for diabetes mellitus, Type II The Veteran contends that his diabetes mellitus is due to exposure to herbicide agents during active service. Specifically, he asserts that he was exposed to herbicide agents while working near the perimeter as part of his military duties while stationed at U-Tapao Royal Thai Air Force Base in Thailand. VA laws and regulations provide that if a veteran was exposed to an herbicide agent during service, certain listed diseases, including diabetes mellitus, Type II, are presumed to be related to that herbicide exposure, and absent affirmative evidence to the contrary, service connection is granted on a presumptive basis. 38 U.S.C. § 1116(a)(1); 38 C.F.R. § 3.309(e). A veteran who “served in the Republic of Vietnam” between January 9, 1962 and May 7, 1975 is presumed to have been exposed during such service to an herbicide agent. 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). VA initially interpreted the applicable regulation to mean that the presumption of service connection applies to those service members who physically set foot in Vietnam. See Haas v. Peake, 544 F.3d 1306, 1308 (Fed. Cir. 2008). More recently, VA expanded the presumption of in-service herbicide exposure to include service in the 12 nautical mile offshore waters of the Republic of Vietnam. See 38 U.S.C. § 1116A (effective January 1, 2020). Additionally, the presumption of in-service herbicide exposure is also extended to certain Vietnam era veterans who served in Korea, and certain Air Force veterans who regularly and repeatedly operated, maintained, or served onboard C-123 aircraft that were known to have been used to spray an herbicide agent during the Vietnam era. 38 C.F.R. § 3.307(a)(6)(iv), (v). Although the presumption of in-service herbicide exposure does not extend to veterans who served in Thailand during the Vietnam era, VA now recognizes that tactical or tactical-like herbicides were used on the fenced-in perimeters of military bases in Thailand. See Veterans Benefits Administration (VBA) C&P Service Bulletin (May 2010). While the Veteran is not entitled to a presumption of in-service herbicide exposure as a result of service in Thailand, due consideration is given as to whether exposure to herbicide agents can be conceded on a facts-found basis for certain veterans who served in Thailand. Exposure to herbicides on a factual basis may be extended to Veterans whose duties placed them on or near the perimeters of Thailand Air Bases during the Vietnam era, to include U-Tapao Royal Thai Air Force Base, Ubon Royal Thai Air Force Base, Nakhon Phanom Royal Thai Air Force Base, Udorn Royal Thai Air Force Base, Takhli Royal Thai Air Force Base, Korat Royal Thai Air Force Base, and Don Muang Royal Thai Air Force Base. The majority of troops in Thailand during the Vietnam era were stationed at one of these bases. If a Veteran served on one of these air bases as a security policeman, security patrol dog handler, member of a security police squadron, or otherwise served near the air base perimeter, as shown by military occupational specialty (MOS), performance evaluations, or other credible evidence, then herbicide exposure may be acknowledged on a facts-found or direct basis. For the following reasons, entitlement to service connection for diabetes mellitus is warranted. VA treatment records indicate that the Veteran has a diagnosis of and post-service treatment for diabetes mellitus. The Veteran’s STRs and military personnel records indicate that the Veteran was stationed in Thailand in the U-Tapao Royal Airfield (U-Tapao) from June 1966 to May 1967. In a September 2009 statement in support of claim, the Veteran stated that he was stationed in Thailand and that their basecamp was sprayed with defoliant. In a March 2020 statement, the Veteran stated that he was stationed at U-Tapao from June 30, 1966 through May 23, 1967. He stated that upon his arrival, there was still a lot of uncleared jungle and he saw trucks spraying defoliant or herbicides around the area and perimeter. He stated that they were housed in tents near the perimeter of the bases and that they sprayed around the tents as well. While stationed at U-Tapao, he worked as a concrete mason while, laying concrete for several different assignments, including revetments for the airplanes. He stated that he laid concrete for the perimeter radar along the runway, noting that alongside the runway was still jungle at that time. He stated that he laid concrete for the engine testing areas, peers for the trailers that housed the pilots, and for several warehouses or flight hangers. He stated that approximately 4 or 5 times while stationed at U-Tapao, he had to go on perimeter guard. He stated that when an alert was given, he had to go to an assigned portion of the perimeter and into the jungle and guard the base, sometimes for 5 hours at a time. He stated also that the dumpster site was set well into the jungle or perimeter of the base. Research and reports submitted by the Veteran in March 2020 show multiple other veterans reporting exposure to herbicide agents during their service at U-Tapao around the same time as the Veteran. The reports address possible exposure to Agent Orange on Thailand military bases. The Veteran’s descriptions are credible and consistent with the circumstances of his service and the evidence in his personnel record. Although the personnel records do not specifically note that the Veteran’s duties required him to go to the perimeter of the base, the personnel records and lay statements show that he was stationed at U-Tapao. The Veteran’s military specialty occupation (MOS) was masonry specialist and included multiple activities around the airfield, which would likely include the perimeter of the base. There is no affirmative evidence to explicitly contradict the Veteran’s reports of being at the perimeter of the base and they are consistent with the places, types, and circumstances of his service. See 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a) (each disabling condition for which a veteran seeks service connection must be considered based on factors including the basis of places, types, and circumstances of service as shown by service record). The overall evidence demonstrates that it was likely the Veteran served “near the perimeter” while at U-Tapao in performing his duties as a masonry specialist. While the Veteran does not have the requisite service in Vietnam or Korea to warrant entitlement to the presumption of in-service herbicide exposure, he does have the requisite service in Thailand to warrant consideration of in-service herbicide exposure on a facts-found basis. The totality of the evidence in this case, the most pertinent of which is summarized above, is in relative equipoise as to whether the Veteran was exposed to an herbicide agent in Thailand. The reasonable doubt created by the relative equipoise in the evidence must be resolved in favor of the Veteran; therefore, exposure to an herbicide agent during service near the U-Tapao air base perimeter is conceded based on the facts found. As the Veteran has been found to have been exposed to in-service herbicides, and his diagnosed diabetes is one of the listed diseases that is presumed to be due to such in-service herbicide exposure, entitlement to service connection for diabetes is therefore warranted. 3. Entitlement to service connection for left lower extremity neuropathy 4. Entitlement to service connection for left upper extremity neuropathy 5. Entitlement to service connection for right lower extremity neuropathy 6. Entitlement to service connection for right upper extremity neuropathy The Veteran contends that his claimed neuropathy of the left lower extremity, left upper extremity, right lower extremity, and right upper extremity are related to active service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of neuropathy of the left lower extremity, left upper extremity, right lower extremity, or right upper extremity and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). VA treatment records indicate that there was no diabetic neuropathy noted on February 11, 2010, and that the Veteran denied neuropathy in a January 8, 2010 record. VA treatment records received in December 2018 do not indicate treatment, complaints, or diagnoses of neuropathy. While the Veteran believes he has a current diagnosis of neuropathy of the bilateral upper and lower extremities, he is not competent to provide a diagnosis in this case. The issue is medically complex, and the Veteran has denied neuropathy symptoms in VA treatment records. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence, indicating no evidence of neuropathy. In disability compensation claims, VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Appellant’s service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold under McLendon is low. To date, the Veteran has not been afforded a VA examination for his claimed neuropathy of the left and right upper and lower extremities. While the Veteran has stated that he has neuropathy, there is no competent evidence of a current disability. Thus, a VA examination under the standards of McLendon is not warranted at this time. The Board has considered the Veteran’s contentions but finds the STRs and medical evidence of record to be highly probative. According to this evidence, the Veteran does not have a current diagnosis of neuropathy. In weighing the evidence of record, the Board finds that the Veteran’s contentions are outweighed by the competent and probative evidence of record. Medical evidence of record is sufficient to decide this claim and it does not indicate a link between the Veteran’s claimed conditions and service. Therefore, the Board finds that the preponderance of the evidence is against a grant of service connection for neuropathy of the left lower extremity, left upper extremity, right lower extremity, and right upper extremity. Hence, the appeal must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 7. Entitlement to service connection for sleep apnea The Veteran contends that his claimed sleep apnea is related to service. While VA treatment records indicate that the Veteran has a diagnosis of and post-service treatment for sleep apnea, there is no competent evidence of record linking the Veteran’s claimed condition to service. The evidence does not indicate that the Veteran had sleep apnea or symptoms of sleep apnea during service or shortly after separation from service. STRs indicate no related complaints, treatment, or diagnoses. The Board has considered the Veteran’s contentions but finds the STRs and medical evidence of record to be highly probative. According to this evidence, the Veteran’s sleep apnea did not have its onset during service and is not otherwise related to service. In weighing the evidence, the Board finds that the Veteran’s contentions are outweighed by the competent and probative evidence of record. To date, the Veteran has not been afforded a VA examination for his claimed sleep apnea. While the record shows that the Veteran has a current diagnosis of sleep apnea, there is no evidence establishing that it began in service or is otherwise related to service. The competent medical evidence of record is sufficient to decide this claim. Thus, a VA examination under the standards of McLendon is not warranted at this time. Medical evidence of record is sufficient to decide this claim and it does not indicate a link between the Veteran’s claimed conditions and service. Therefore, the Board finds that the preponderance of the evidence is against a grant of service connection for sleep apnea. Hence, the appeal must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 8. Entitlement to service connection for pressure in eyes The Veteran contends that his claimed pressure in eyes condition is related to service. All veterans are considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, except where clear and unmistakable evidence demonstrates that an injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111. This presumption attaches only where there has been an induction examination in which the later complained-of disability was not detected. See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The regulation provides expressly that the term “noted” denotes “[o]nly such conditions as are recorded in examination reports,” 38 C.F.R. § 3.304(b), and that “[h]istory of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions.” Id. at(b) (1). If a disorder was not “noted” on entering service, the government must show clear and unmistakable evidence of both a preexisting condition and a lack of in-service aggravation to overcome the presumption of soundness. A lack of aggravation may be shown by establishing that there was no increase in disability during service or that the “increase in disability [was] due to the natural progress of the preexisting condition.” 38 C.F.R. § 3.306; Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). If the government fails to rebut the presumption of soundness, the claim is one for service connection, not aggravation. Wagner, 370 F.3d at 1097. Here, as discussed below, defective vision was noted at entry into service; and, periodic examinations conducted during service and at separation show that the Veteran reported eye trouble. However, it was always clarified that the “eye trouble” reported by the Veteran referred to defective vision, a congenital defect not subject to service connection. There was no indication of pressure in the eyes, glaucoma, dry eyes, or other eye disorder at entry, or at any time during service. As such, the Veteran is presumed sound at entry with respect to the claim of service connection for pressure in the eyes. While VA treatment records indicate that the Veteran has post-service treatment for dry eyes, there is no competent evidence of record linking the Veteran’s claimed condition to service. The evidence does not indicate that the Veteran had pressure in his eyes during service. STRs indicate that the Veteran’s enlistment examination indicates eye trouble and that the Veteran “wears corrective glasses.” A February 1966 report of medical examination indicates that “eye trouble refers to corrective lenses worn since childhood, no comp.” STRs indicate that the Veteran reported eye trouble on the February 1967 separation examination, report of medical history, explaining that the “eye trouble refers to the fact that he wears corrective lenses.” The STRs indicate no other related complaints, treatment, or diagnoses related to pressure in his eyes. The Board has considered the Veteran’s contentions but finds the Veteran’s STRs and medical evidence of record to be highly probative. According to this evidence, the Veteran’s claimed pressure in eyes did not have its onset during service and is not otherwise related to service. In weighing the evidence of record, the Board finds that the Veteran’s contentions are outweighed by the competent and probative evidence of record. To date, the Veteran has not been afforded a VA examination for his claimed pressure in eyes. While VA treatment records indicate that the Veteran has post-service treatment for dry eyes, there is no competent evidence of record linking the Veteran’s claimed condition to service. The competent medical evidence of record is sufficient to decide this claim. Thus, a VA examination under the standards of McLendon is not warranted at this time. Medical evidence of record is sufficient to decide this claim and it does not indicate a link between the Veteran’s claimed conditions and service. Therefore, the Board finds that the preponderance of the evidence is against a grant of service connection for pressure in eyes. Hence, the appeal must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for hypertension The Veteran contends that his claimed hypertension is related to service. Here, the Veteran has not been provided with a VA examination or opinion regarding his claimed hypertension. In the above decision, the Board has conceded exposure to herbicide agents to include Agent Orange based on his service at U-Tapao Royal Thai Air Force Base. Although hypertension is not presently amongst the delineated diseases associated with herbicide agent exposure pursuant to 38 C.F.R. § 3.309(e), service connection for claimed residuals of exposure to herbicide agents may be established with evidence of actual causation. 38 C.F.R. § 3.309(e); Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange). To that end, the National Academy of Sciences (NAS) had previously placed hypertension in the category of "limited or suggestive evidence of an association" with exposure to herbicides. See e.g., Health Effects Not Associated with Exposure to Certain Herbicide Agents, 75 Fed. Reg. 32,540, 32,549 (June 8, 2010). In November 2018, the NAS moved hypertension to the category of "sufficient" evidence of an association from its previous classification in the "limited or suggestive" category. The sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association between hypertension and exposure to Agent Orange. See Veterans and Agent Orange: Update 2018. Nevertheless, the NAS finding of "sufficient" evidence of an association between hypertension and exposure to herbicides does not provide evidence that this appellant's hypertension is caused by exposure to herbicides, because VA has not added hypertension to the list of diseases presumed to be associated with in-service herbicide exposure; and, evidence suggesting an association is not the same as evidence of causation. Nonetheless, the NAS study raises "an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service...." McLendon v. Nicholson, 20 Vet. App. 79, 86 (2006). The appellant has been diagnosed with hypertension. As such, an etiological opinion should be obtained. The matter is REMANDED for the following action: 1. Schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) with regard to his service connection claim for hypertension. The examiner must review the claims file in conjunction with the examination. (a.) The examiner must provide a medical opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s hypertension is related to service and/or had its onset during service, to include exposure to herbicide agents, such as Agent Orange, which has been conceded in this case. (b.) The examiner must provide a medical opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s hypertension is proximately caused or aggravated by a service-connected disability. The examiner must support any opinion rendered with a detailed rationale. If the examiner cannot provide the above opinion, the examiner is advised that he or she must explain why the requested opinion cannot be provided. The term “at least as likely as not” does not mean within the realm of possibility, but rather that the evidence both for and against a conclusion is so evenly divided that it is as sound to find in favor of a certain conclusion as it is to find against it. L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Labi, 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.