Citation Nr: 21062105 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 16-00 367 DATE: October 6, 2021 REMANDED Service connection for hypertension is remanded. Service connection for chronic kidney disease is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1965 to July 1967, including in the Republic of Vietnam. In October 2018 and May 2021, the Board of Veterans' Appeals (Board) remanded his claims to the agency of original jurisdiction (AOJ) for additional development. As explained below, another remand is now necessary. 1. Service connection for hypertension is remanded. The Veteran attributes his hypertension to Agent Orange exposure in Vietnam. Although he was presumptively exposed to herbicide agents, hypertension is not one of the diseases associated with herbicide agent exposure listed at 38 C.F.R. § 3.309(e). Presumptive service connection is therefore not available on that basis. The Board asked the AOJ to obtain a VA medical opinion on direct service connection. See e.g., Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994) (the availability of presumptive service connection does not preclude a veteran from establishing service connection with proof of direct causation). A February 2021 examiner reasoned, essentially, that the Veteran's hypertension was not related to service because hypertension is not on "VA's presumptive diagnosis list" (i.e., 38 C.F.R. § 3.309(e)). The Board found this opinion inadequate because it was conclusory, and because the examiner failed to discuss medical literature on the relationship between herbicide agents and hypertension, as instructed. The Board remanded for an addendum opinion. The AOJ obtained one in August 2021. First, the August 2021 examiner determined, based on medical literature, that there is at least as likely as not "an association" between hypertension and Agent Orange exposure. The examiner noted, however, that "association does not constitute etiology." The examiner did not explain this distinction. The August 2021 examiner then determined that the Veteran's hypertension was less likely than not incurred in service or caused by herbicide agents. This conclusion appears to be based on VA's presumptive service connection regulations, rather than any facts particular to the Veteran's case. The examiner stated that VA "has not included hypertension as a presumptive condition due to exposure to agent orange chemicals or other herbicides," and that the examiner did not "have authorization" to do so. Notably, the opinion does not discuss the Veteran's medical history or any details about his specific disability. The Board finds the August 2021 opinion inadequate because it is not based on consideration of the Veteran's prior medical history and examinations, and it does not describe his disability in sufficient detail to allow for a fully informed decision. D'Aries v. Peake, 22 Vet. App. 97, 104 (2008). Additionally, the opinion is ambiguous because the examiner did not explain why the "positive association" between hypertension and Agent Orange in the medical literature was not sufficient to establish "etiology" in the Veteran's particular case. Monzingo v. Shinseki, 26 Vet. App. 97, 109 (2012). Another remand for an adequate opinion is warranted. 2. Service connection for chronic kidney disease is remanded. The Veteran contends that his chronic kidney disease is also due to Agent Orange exposure, and/or secondary to hypertension. The Board noted in the prior remand that these two claims are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991); Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim). Because the Board is remanding the hypertension claim, the kidney disease claim is also remanded. The Board notes that there is no opinion on file as to whether the Veteran's kidney disease is proximately due to or aggravated by his hypertension. See El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). The AOJ should obtain one on remand. The Board by this remand makes no determination, expressed or implied, concerning the credibility of any statements on file. The matters are REMANDED for the following action: 1. Obtain an addendum opinion on the nature and etiology of the Veteran's hypertension. After reviewing the claims file, including this remand, the examiner must provide an opinion on whether it is at least as likely as not (50 percent or greater probability) that his hypertension was incurred in, or it otherwise related to service, including to presumptive herbicide agent exposure. The examiner should discuss the medical literature summarized in the previous VA opinions of record. 2. Obtain an addendum opinion on the nature and etiology of the Veteran's chronic kidney disease. After reviewing the claims file, including this remand, the examiner must provide an opinion on the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's chronic kidney disease is proximately due to his hypertension? (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's chronic kidney disease is aggravated beyond its natural clinical course by his hypertension? 3. Review the medical opinions above to ensure substantial compliance with the Board's directives. Take any necessary corrective action. 4. Readjudicate the Veteran's claims. If any claim remains denied, issue a supplemental statement of the case and allow the Veteran the opportunity to respond. Then return to the Board for further appellate review. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D.Z. Wall, 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.