Citation Nr: 21064757 Decision Date: 10/21/21 Archive Date: 10/21/21 DOCKET NO. 16-22 570 DATE: October 21, 2021 ORDER Entitlement to service connection for hypertension is granted. REMANDED Entitlement to service connection for residuals of a cerebrovascular accident (CVA) is remanded. Entitlement to special monthly compensation (SMC) based on loss of use of both hands and/or both feet is remanded. FINDING OF FACT Resolving reasonable doubt in the appellant's favor, the Veteran's hypertension was due to in-service exposure to herbicide agents. CONCLUSION OF LAW The criteria for service connection for hypertension are met. 38 U.S.C. §§ 1110, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from November 1967 to September 1969, to include service in the Republic of Vietnam. He died in June 2020, and the appellant is his surviving spouse, who has been properly substituted in this appeal. This case initially came before the Board of Veterans' Appeals (Board) on appeal from a July 2014 rating decision issued by a Regional Office (RO) of the Department of Veterans' Affairs (VA). In September 2018 and April 2021, the Board remanded the claims for additional development. The case has since been returned to the Board. Service Connection - Hypertension The evidence indicates that the Veteran served in the Republic of Vietnam during the Vietnam era. Therefore, it is presumed that he was exposed to herbicide agents. See 38 C.F.R. § 3.307(a)(6)(iii). The evidence also indicates that he was diagnosed with hypertension. Although hypertension is not presumptively related to herbicide exposure, 38 C.F.R. § 3.309(e), in 2018, the National Academy of Sciences (NAS) determined that there is "sufficient" epidemiologic evidence to conclude that there is a positive association between hypertension and herbicide exposure. In April 2014 and September 2020, VA examiners provided medical opinions regarding whether the Veteran's hypertension was caused or aggravated by his service-connected diabetes mellitus. Those opinions, which the Board found inadequate, did not address whether his hypertension was directly related to service, to include herbicide exposure. In April 2021, the Board remanded the claim for an additional VA medical opinion to address whether the Veteran's hypertension was at least as likely as not due to in-service herbicide exposure and to provide a more thorough opinion regarding whether his hypertension was caused or aggravated by his service-connected diabetes mellitus. In July 2021, a VA examiner noted that in addition to herbicide exposure, the Veteran had multiple risk factors for hypertension, including overweight/obese body habitus, dyslipidemia, diabetes type 2, tobacco dependency, and age. The examiner stated that because of the multiple risk factors, it was difficult to ascertain with 50 percent or greater probability that the Veteran's hypertension could be isolated to herbicide exposure alone. Ultimately, the examiner opined that it was less likely than not that his hypertension was incurred in or caused by service, to include herbicide exposure. The Board notes, however, that at least two of the Veteran's risk factors for hypertension that were identified by the VA examiner, i.e., herbicide exposure and diabetes mellitus, are related to service. Although the examiner ultimately provided a negative opinion, the rationale provided was much more equivocal. The Board notes that is not necessary that herbicide exposure, alone, caused the Veteran's hypertension. It is only necessary that his hypertension was at least as likely as not caused by or related to service, either due to in-service herbicide exposure or service-connected diabetes mellitus or a combination of both. Notably, the examiner did not indicate that the Veteran's nonservice-related risk factors more likely caused his hypertension. For these reasons, the Board finds the July 2021 VA examiner's opinion lacks probative value. In this case, the Veteran is presumed to have been exposed to herbicides while serving in the Republic of Vietnam, and he had a diagnosis of hypertension. There is no probative VA medical opinion of record against the claim. Rather, there is sufficient evidence to conclude that there is a positive association between hypertension and herbicide exposure. Accordingly, the Board finds that the evidence for and against the claim of entitlement to service connection for hypertension is at least in equipoise. Therefore, reasonable doubt must be resolved in favor of the appellant and entitlement to service connection for hypertension is warranted. 38 U.S.C. § 5107(b) (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND Unfortunately, the Board's review of the claims file reveals that further Agency of Jurisdiction (AOJ) action is warranted, even though such action will, regrettably, further delay an appellate decision on the issues remaining on appeal. In April 2014, a VA examiner opined that the Veteran's CVA was less likely than not caused by his service-connected diabetes mellitus. He noted that the Veteran had multiple risk factors for CVA, including long-standing poorly controlled hypertension among others. Given that the Board had granted service connection for hypertension, a remand is necessary for an additional VA medical opinion regarding the nature and etiology of the Veteran's CVA. The appellant maintains that the Veteran's CVA resulted in loss of use of both hands and feet thereby entitling him to SMC. Because the issues are inextricably intertwined, adjudication of the claim for SMC must be deferred pending final disposition of the claim for service connection for residuals of a CVA. See Henderson v. West, 12 Vet. App. 11, 20 (1998). The matters are REMANDED for the following action: 1. Obtain a VA medical opinion from a VA examiner with appropriate expertise to determine the nature and etiology of the Veteran's CVA and residuals. The claims file must be made available to, and reviewed by the examiner. After a review of the evidence of record, to include consideration of any newly received records, the examiner should provide an opinion as to whether the Veteran's CVA and any residuals were at least as likely as not (50 percent or better probability) caused or aggravated by his service-connected hypertension and/or diabetes mellitus. The examiner should also describe the remaining function in the Veteran's hands and feet resulting from his CVA and service-connected diabetes mellitus, including his ability to grasp and manipulate objects and any impact on balance and propulsion. If the examiner cannot different the symptoms due to his nonservice-connected disabilities from the symptoms due to his service-connected disabilities, the examiner should so state in the report and explain why. A rationale for all opinions expressed must be provided. 2. Confirm that the VA examination report and all opinions provided comport with this remand and undertake any other development found to be warranted. 3. Then, readjudicate the issues remaining on appeal. If a decision is adverse to the appellant, issue a supplemental statement of the case and allow appropriate time for response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Mishalanie, 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.