Citation Nr: 21061634 Decision Date: 10/04/21 Archive Date: 10/04/21 DOCKET NO. 16-58 084 DATE: October 4, 2021 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for bilateral upper extremity peripheral neuropathy, to include median nerve paralysis, is remanded. Entitlement to service connection for bilateral lower extremity peripheral neuropathy is remanded. REASONS FOR REMAND The Veteran served in the United States Marine Corps on active duty from February 1968 to August 1969. The issues come before the Board of Veterans' Appeals (Board) on appeal from a June 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The issues were previously before the Board in July 2019. The Board remanded for further development. Although the Board regrets further delay, another remand is necessary to provide the Veteran with every possible consideration. Further development is necessary prior to appellate review to provide the Veteran with adequate VA medical opinions. 1. Entitlement to service connection for hypertension is remanded. The Veteran contends that his diagnosis of hypertension is related to his active service, to include as a result of herbicide agent exposure while serving in the Republic of Vietnam. Pursuant to the July 2019 Board remand, the RO provided the Veteran a VA hypertension examination in December 2019. The VA examiner provided the opinion that it was less likely than not that the Veteran's hypertension was incurred in or caused by an in-service injury, event, or illness, to include presumed in-service exposure to herbicide agents. Notably, the VA examiner stated the Veteran has never taken medication to control his hypertension. The VA examination reported the Veteran's blood pressure was not elevated and he still was not taking medication or controlling his hypertension with diet or exercise. Additionally, the VA examiner stated that the opinion offered was mere speculation. The December 2019 VA medical opinion is inadequate to adjudicate the Veteran's claim, as the opinion is based on an inaccurate factual premise. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The Veteran's May 2019 VA medical treatment records show the Veteran managed his blood pressure with a low salt diet and frequent exercise. Moreover, the Veteran's February 2007 VA treatment record revealed the Veteran's primary care physician prescribed daily medication to control elevated blood pressure. Thus, the Board finds the December 2019 VA examination and medical opinion are inadequate, and remand is required to provide the Veteran a medical opinion, not based entirely on speculation, accurately addressing the Veteran's medical history. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 299-304 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). 2. Entitlement to service connection for bilateral upper and lower extremity peripheral neuropathy is remanded. The Veteran asserts that he developed peripheral neuropathy in his upper and lower extremities as a result of exposure to herbicides during his service in the Republic of Vietnam. The Veteran underwent a VA peripheral nerve condition examination in December 2019. The VA examiner provided that it was less likely than not that the Veteran's peripheral neuropathy in his upper and lower extremities was incurred in or caused by an in-service injury, event, or illness, to include presumed in-service exposure to herbicide agents. The examiner stated the onset of the Veteran's upper and lower extremity peripheral neuropathy was greater than 30 years after separation for service, which did not qualify as an earlier onset to exposure. The Board must consider all theories of entitlement either expressly raised by the claimant or which are reasonably raised by the record. See Robinson v. Shinseki, 557 F.3d 1355, 1362 (Fed. Cir. 2009). Further, when VA determines to provide an examination or obtain a VA opinion, it must ensure that the examination adequately considers the evidence of record addressing the Veteran's medical history. See Barr, 21 Vet. App. at 312; see also Nieves-Rodriguez, 22 Vet. App. at 304. Moreover, the VA examiner must address the Veteran's relevant lay statements to provide the Board with an adequate medical opinion. Miller v. Wilkie, 32 Vet. App. 249, 260 (2020). A review of the Veteran's claims file shows the Veteran has complained of neuropathy since service. In a May 2005 VA examination, the Veteran complained of radiating pain and stiffness down both shoulders with an onset in bootcamp. Additionally, the Veteran testified before the RO at a hearing in December 2018 that he experienced symptoms in his hands while in service but did not seek medical treatment because he only thought it was from overexertion. Further, the Veteran stated he realized his hands were "no good anymore" two to five years out of service. The Board finds remand is required to adequately address the lay evidence offered by the Veteran reporting the onset of the Veteran's upper and lower extremity peripheral neuropathy. Additionally, the Board notes that the unavailability of presumptive service connection for some conditions based on exposure to herbicide agents does not preclude direct service connection based on herbicide agent exposure. 38 C.F.R. §§ 3.307, 3.309; Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Stefl, 21 Vet. App. at 120. Accordingly, remand is needed to provide the Veteran with a VA examination that provides a medical opinion regarding the Veteran's direct service connection, as well as presumptive service connection theories of entitlement. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination with an appropriate examiner to determine the etiology of the Veteran's claimed hypertension. The record and a copy of this Remand must be made available to the examiner. The examination may be conducted via telehealth or similar service during the social distancing restrictions of the COVID-19 pandemic. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail, and correlated to a specific diagnosis. Following a review of the evidence of record, the examiner must opine as to whether it is at least as likely as not (50 percent probability or more) that the Veteran's hypertension had its onset during or is otherwise etiologically related to active-duty service, to include presumed in-service herbicide agent exposure. Pursuant to the July 2019 Board Remand, for the purpose of the examination, the clinician must specifically address the November 2018 Veteran's and Agent Orange: Update 11, citing a recent NAS report indicating that there is "sufficient" evidence of an association between hypertension and herbicide exposure. The examiner must provide a comprehensive report including a clearly stated rationale for any opinions offered and conclusions reached, citing the objective medical findings leading to the conclusions, which must not be based solely on the lack of records. In this regard, the Board emphasizes that the Veteran is competent to report his symptoms and history, and such statements by the Veteran regarding symptomatology and medical history must be specifically acknowledged and considered in formulating any opinions concerning the onset and severity of his disability. If such reports are rejected by the examiner, a reason for doing so must be provided. 2. Schedule the Veteran for a VA examination with an appropriate examiner to determine the etiology of the Veteran's claimed peripheral neuropathy of the bilateral upper and lower extremities. The record and a copy of this Remand must be made available to the examiner. The examination may be conducted via telehealth or similar service during the social distancing restrictions of the COVID-19 pandemic. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail, and correlated to a specific diagnosis. Following a review of the evidence of record, the examiner must opine as to: (a.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran's upper extremity peripheral neuropathy had its onset during or is otherwise etiologically related to active-duty service, to include presumed in-service herbicide agent exposure. (b.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran's lower extremity peripheral neuropathy had its onset during or is otherwise etiologically related to active-duty service, to include presumed in-service herbicide agent exposure. The examiner must provide a comprehensive report including a clearly stated rationale for any opinions offered and conclusions reached, citing the objective medical findings leading to the conclusions, which must not be based solely on the lack of records. In this regard, the Board emphasizes that the Veteran is competent to report his symptoms and history, and such statements by the Veteran regarding symptomatology and medical history must be specifically acknowledged and considered in formulating any opinions concerning the onset and severity of his disability. If such reports are rejected by the examiner, a reason for doing so must be provided. JENNIFER HWA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.V. Bona, 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.