Citation Nr: 21068826 Decision Date: 11/15/21 Archive Date: 11/15/21 DOCKET NO. 13-00 299 DATE: November 15, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to herbicide exposure, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1966 to April 1968. This matter is before the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in January 2014. A transcript of the hearing is associated with the electronic claims file. The Board issued a prior remand on this claim in February 2015 and a decision on this claim in October 2018. However, following an appeal to the United States Court for Appeals for Veterans Claims, in September 2019 a Joint Motion for Partial Remand (Joint Motion) was entered, vacating portions of the Board's October 2018 decision. In compliance with the Joint Motion, the Board issued another remand in June 2020. 1. Entitlement to service connection for hypertension, to include as secondary to herbicide exposure, is remanded. The Board regrets further delay; however, the November 2020 addendum opinion is not in compliance with the June 2020 Board remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding remand by the Board confers on the claimant the right to compliance with the remand requests). First, the opinion is internally inconsistent, providing a positive nexus opinion, but negative rationale. Second, the examiner did not respond to each of the questions in the June 2020 remand directives. And third, the examiner specializes in occupational medicine, despite the Board specifically instructing that the opinion be rendered by an internist. Accordingly, another remand is warranted to obtain an adequate addendum opinion. The matters are REMANDED for the following action: 1. Obtain an addendum opinion regarding the Veteran's hypertension by an Internist (M.D.). A copy of the Veteran's entire claim file, including this remand, should be provided to the physician and a note that such was reviewed should be included in the report. The examiner should answer the following questions: (a.) Is it at least as likely as not (50 percent probability or greater) that the Veteran's hypertension is etiologically related to his presumed in-service herbicide exposure? The Board is cognizant that there is no VA presumption of service connection for hypertension due to herbicide exposure. However, the examiner should consider the National Academy of Sciences upgrade of hypertension to the "sufficient" category from "limited or suggestive," indicating that "there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and herbicide exposure (see Veterans and Agent Orange: Update 11 (2018)). In formulating an opinion, the Board requests that the examiner consider the likelihood that THIS Veteran's hypertension is related to HIS herbicide exposure given HIS medical history, family history, absence of other risk factors, etc. (b.) In light of the March 2014 affidavit from B.B. is it at least as likely as not (50 percent probability or greater) that the Veteran's hypertension is etiologically related to his: 1. in-service elevated blood pressure readings; 2. in-service kidney infection; and/or 3. medication taken to treat the kidney infection. The examiner should specifically discuss the effects of any medication the Veteran took for his kidney infection. Moreover, the examiner is requested to specifically discuss and consider the January 2012 VA examination wherein the Veteran reported that he began taking medication for his hypertension in the fall of 1968. (c.) Is it at least as likely as not (50 percent probability or greater) that the Veteran's hypertension was caused by his PTSD? (d.) Is it at least as likely as not (50 percent probability or greater) that the Veteran's hypertension was aggravated (i.e., any increase in severity not due to the natural progress of the disease) by his PTSD? A detailed rationale for the opinion must be provided. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 2. After the addendum opinion is obtained, the RO should ensure that all remand directives have been addressed prior to returning the case back to the Board. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Ruiz, 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.