Citation Nr: 21070707 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 16-45 734 DATE: November 24, 2021 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for obstructive sleep apnea is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from July 1965 to July 1968, to include service in the Republic of Vietnam. For his meritorious service, the Veteran was awarded the Vietnam Service and Campaign Medals. This matter is before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The issues were remanded in August 2019 and October 2020 by the Board for further development. 1. Entitlement to service connection for hypertension is remanded. In its previous October 2020 remand, the Board sought additional competent guidance as to whether the Veteran's claimed hypertension is related to his active service or to any service-connected disability. As noted, however, the Veteran served in the Republic of Vietnam, and he is presumed to have been exposed to herbicide agents as a result of that service. 38 C.F.R. § 3.307. While hypertension is not a disability that is currently among those presumed to be related to herbicide agent exposure, a recent update from the National Academy of Sciences moved hypertension from the limited or suggestive evidence category to the sufficient evidence of an association category. As such, an additional opinion regarding any possible relationship between the Veteran's hypertension and his active service, to include his presumed exposure to herbicide agents, must be obtained. While the most recent VA examiner did discuss herbicide agent exposure, that discussion was done within the context of the relative likelihood and amount of the Veteran's exposure to herbicide agents. Given the Veteran's service in the Republic of Vietnam, however, his exposure is conceded by regulation. Accordingly, any opinion obtained as a result of this remand must simply determine, based on the updated guidance, whether the Veteran's hypertension is related to his presumed in-service herbicide agent exposure. 2. Entitlement to service connection for obstructive sleep apnea is remanded. In an October 2020 Board decision, the Board requested that the Veteran's private sleep study reports from March 2008 and January 2019 be obtained. Subsequently, the RO obtained the January 2019 sleep study report, but the March 2008 sleep study report was not obtained. On remand, the RO should obtain the March 2008 private sleep study report. There is evidence that sleep apnea is possibly linked to hypertension. See September 2020 Appellate. As service connection for hypertension is granted in this decision, a remand is warranted for consideration of whether the Veteran's obstructive sleep apnea is secondary to his service-connected hypertension. Furthermore, in the September 2020 Appellate Brief, the Veteran's representative cited to a medical article that suggested that sleep apnea was linked to diabetes, hypertension, and cardiovascular problems. The new July 2021 and August 2021 VA medical opinions do not discuss this evidence. Therefore, a remand is warranted to obtain a new VA addendum medical opinion to consider this medical article. The matters are REMANDED for the following action: 1. Obtain the March 2008 private sleep study report. If this report cannot be obtained, the reasons should be noted in the record. See June 2012 Medical Treatment Record Non Government Facility. 2. Obtain an addendum opinion regarding the Veteran's hypertension. Specifically, an appropriate examiner is to state whether it is at least as likely as not that the Veteran's current hypertension is related to his active service, to include his presumed exposure to herbicide agents therein. In providing this opinion, the examiner must cite to the recent update from the NAS regarding hypertension and herbicide agent exposure. The examiner may not base a negative opinion on the fact that hypertension is not listed as a presumptive disability. Instead, a review of relevant medical literature, to include the NAS update, must be discussed in the opinion. Further, the examiner must presume that the Veteran was exposed to herbicide agents as a result of his service in the Republic of Vietnam. 3. After the above development has been completed, obtain a VA addendum medical opinion regarding the nature and etiology of the Veteran's sleep apnea. If a medical opinion cannot be rendered without a VA examination, then a VA examination should be scheduled and performed. The VA examination should review a copy of the remand and this claims file. The VA examiner should address the following: (a.) Is it at least as likely as not that the Veteran's obstructive sleep apnea is proximately due to, caused by, and/or aggravated by his service-connected hypertension? The VA examiner should discuss the medical article cited to in the September 2020 Appellate Brief. (b.) Is it at least as likely as not that the Veteran's obstructive sleep apnea is proximately due to, caused by, and/or aggravated by his service-connected type II diabetes mellitus? The VA examiner should discuss the Medical article cited to in the September 2020 Appellate Brief. (c.) Is it at least as likely as not that the Veteran's obstructive sleep apnea is proximately due to, caused by, and/or aggravated by his service-connected coronary artery disease status post 6 vessel stent placement? The VA examiner should discuss the medical article cited to in the September 2020 Appellate Brief. (Continued on next page) All opinions must be supported by a sufficient rationale. A negative opinion cannot be solely based on the absence of medical evidence. Evan M. Deichert Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Crawford, 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.