Citation Nr: 21065427 Decision Date: 10/26/21 Archive Date: 10/26/21 DOCKET NO. 16-04 696 DATE: October 26, 2021 REMANDED Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran had active service from September 1972 to October 1975. In June 2019, he testified at a videoconference before the undersigned; a transcript of the hearing has been associated with the record. The case was before the Board in February 2020 and again in May 2021, at which time the Board remanded the instant claim for additional development. Regrettably, there has not been substantial compliance with the May 2021 remand directives such that another remand is once again necessary. See Stegall v. West, 11 Vet. App. 268 (1998). Specifically, the Board directed that a medical examiner consider and comment on a November 2018 National Academy of Sciences (NAS) report that moved hypertension from the "limited or suggestive" to "sufficient" category for association with herbicide agents. Medical opinions were obtained in August 2021. An examiner concluded that the Veteran's diagnosed hypertension was not related to service and was not caused or aggravated by the Veteran's service-connected diabetes and/or coronary artery disease with myocardial infarction and cardiomyopathy, to include any medications taken for those disabilities. By way of rationale, the examiner stated that the Veteran's medical records noted signs of hypertension as early as 1975 and subsequently worsened. The examiner noted that the Veteran was noted to have hyperlipidemia, high blood sugar, and periods of poor compliance with maintenance medication. The examiner added that the Veteran was a smoker. Given the foregoing, the examiner concluded that the presence of medically known risk factors in the Veteran's medical history made it difficult to determine that the Veteran's hypertension was caused by exposure to Agent Orange during service. Rather, the examiner stated that age, obesity, hyperlipidemia, and poor lifestyle choices were major risk factors that caused and contributed to hypertension. Identical rationales were offered for the examiner's opinion that hypertension was not caused or aggravated by the Veteran's service-connected diabetes and/or heart disease. First, in noting that there was a sign of hypertension in 1975, without more, it remains unclear whether the examiner was stating that hypertension actually existed at the time of discharge, or not. Second, with respect to the question of whether exposure to herbicides played a role in the development of hypertension, the examiner did not consider or address the NAS report and its findings, as directed by the Board in its prior remand. Last, the examiner did not provide adequate rationales in support of the secondary service connection opinions. In this regard, the examiner seemed to suggest that hypertension was caused by certain medical risk factors including high blood sugar and poor compliance with medication maintenance, but then did not adequately explain why hypertension was unrelated to diabetes or any medications taken for his service-connected conditions. Given the inadequacies, the Board finds remand is necessary to obtain a medical opinion concerning the nature and etiology of the Veteran's hypertension. The matter is REMANDED for the following action: 1. Obtain a medical opinion from an examiner other than the one who provided the May 2021 opinion addressing the etiology of the Veteran's diagnosed hypertension. The selected examiner must review the entire claims file, and then address the following: (a.) Is it at least as likely as not (approximately 50 percent probability) that the Veteran's hypertension had onset during the Veteran's active service? In providing a response, please consider in-service blood pressure readings, to include 140/80 on his examination upon separation, the Veteran's report of post-service heart trouble, to include heart attack, and the August 2021 examiner's statement that there were signs of hypertension as early as 1975. (b.) If hypertension did not have onset during service, is it at least as likely as not that such is related to the Veteran's period of active duty service, to specifically include his presumed exposure to herbicide agents? In providing a response, the examiner must consider and comment upon the most recent November 2018 National Academy of Sciences (NAS) study that moved hypertension from the "limited or suggestive" to "sufficient" category for association with herbicides. Veterans and Agent Orange: Update 11 (2018). (c.) Alternatively, is it at least as likely as not (approximately 50 percent probability) that the Veteran's hypertension has been caused or aggravated by the Veteran's service-connected diabetes or coronary artery disease, to include any medications taken for those disabilities? The examiner must provide a thorough medical rationale for any opinions offered. 2. Then, readjudicate the issue on appeal. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Polly Johnson, 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.