Citation Nr: 21064145 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 16-15 172A DATE: October 19, 2021 REMANDED Entitlement to service connection for right lower extremity neuropathy is remanded. Entitlement to service connection for left lower extremity neuropathy is remanded. Entitlement to service connection for a heart disease is remanded. Entitlement to service connection for hypertension, to include as secondary to herbicide exposure, is remanded. Entitlement to service connection for obstructive sleep apnea, as secondary to hypertension, is remanded. REASONS FOR REMAND In a September 2020 VA Memorandum, the RO determined that the Veteran had Vietnam service. His DD Form 214 indicated that he earned the award of the Vietnam Service medal and the Vietnam Campaign medal. Additionally, his military personnel records indicated service in Vietnam. Finally, his military personnel record of discharge from active duty indicated that the Veteran had "Completed Vietnam Tour More than 90 Days Prior To EAOS." Based on this evidence, the RO conceded herbicide exposure. With regards to the Veteran's neurological issues, in an April 2021 VA examination report, the Veteran was diagnosed with right lower extremity and left lower extremity neuropathy. The VA examiner noted that while neuropathy is a presumptive condition under 38 C.F.R. § 3.309, the Veteran's bilateral lower extremity neuropathy did not appear within one year of service. His symptoms did not begin until about 40 years after service. Because of this, service connection on a presumptive basis was not possible. The examiner noted that there were many etiologies for peripheral neuropathies and explained that vascular and blood problems that decrease oxygen supply to the peripheral nerves can lead to nerve tissue damage. Diabetes, smoking, and narrowing of the arteries from high blood pressure or atherosclerosis and scarring from vasculitis can impede blood flow and cause patchy nerve damage in which isolated nerves in different areas are damaged. The examiner reported that the Veteran had a history of vascular damage in his legs and opined that "It is quite likely that this is the etiology of the Veteran's neuropathy (as he seems to lack the other etiologies. In any case, it is apparent that his neuropathy is less likely than not due to herbicide exposure." The Board finds that this opinion is inadequate and conclusory. The examiner never explained why one of these other etiologies was more likely the cause of the Veteran's bilateral lower extremity neuropathy than his exposure to herbicides. The examiner just says that "It is apparent that [the Veteran's] neuropathy] is less likely than not due to herbicide exposure" without ever explaining why this is. Because of this, a new VA opinion is necessary to determine whether the Veteran's bilateral lower extremity neuropathy was caused or aggravated by active service, to include herbicide exposure or whether it was secondarily related to his now-service-connected hypertension. Regarding the Veteran's heart disease claim, in an April 2021 VA examination report, the Veteran was diagnosed with stable angina and patent foramen ovale (PFO) status-post repair. In the opinion, the examiner goes into great length to explain that PFO is congenital, that there was no evidence to suggest a superimposed injury or disease that resulted in an additional disability, and that there was no record that the Veteran's heart condition pre-existed service. Additionally, the examiner noted that the Veteran's heart condition was not aggravated by service. While the examiner provided an excellent opinion as to why the Veteran should not be service connected for his PFO, no opinion was given as to whether the Veteran's stable angina was related to service. Because of this, a new VA opinion is necessary to determine whether the Veteran's stable angina was caused or aggravated by active service, to include herbicide exposure, or whether it was secondarily related to his now-service-connected hypertension. Respecting the Veteran's hypertension, the Board reflects that the Veteran underwent a VA examination in October 2020, in which he was noted to have hypertension and the examiner opined that hypertension was not directly related to military service. The Board reflects that no opinion regarding herbicide exposure as a cause was given. The Board reflects that the National Academies of Sciences, Engineering, and Medicine, on November 15, 2018, moved hypertension to the category of "sufficient" evidence of an association from its previous classification in the "limited or suggestive" category," indicating that there is enough epidemiologic evidence to conclude that there is a positive association between hypertension and exposure to herbicide agents, including Agent Orange. See National Academy of Science (NAS) November 2018 update report titled, Veterans and Agent Orange Update 11 (2018). Finally, as is already remanding the issue of service connection for a heard disease and hypertension, this claim is intertwined with those claims and is also remanded at this time. See Henderson v. West, 12 Vet. App. 11, 20 (1998); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following actions: Arrange for the Veteran's file to be forwarded to a VA examiner for clarifying addendum opinions regarding the likely cause of the Veteran's bilateral lower extremity neuropathy, heart disease, and hypertension. The examiner or consulting physician must review the entire record (including all updated records obtained pursuant to the above development order). Based on his or her review, the examiner or consulting physician should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's bilateral lower extremity neuropathy, heart disease, and hypertension are directly related to active military service, to include herbicide exposure. Regarding the hypertension, the examiner should specifically address the 2018 NAS study which moved that disease to noted that there was "limited or suggestive" evidence of an association to herbicides. A detailed explanation (rationale) is requested for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested). MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Abrams, 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.