Citation Nr: 21072551 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 18-39 666 DATE: December 3, 2021 REMANDED The appeal as to the claim of entitlement to service connection for a hypertensive disorder, to include as secondary to service-connected diabetes mellitus, is remanded. REASONS FOR REMAND The Veteran had active service in the United States Army from March 1968 to March 1970. His service was under honorable conditions. The Board recognizes that, among other commendations, the Vietnam Service Medal, the Vietnam Campaign Medal, and the Vietnamese Cross of Gallantry were awarded. This matter is on appeal from an April 2017 rating decision. This matter was previously remanded by the Board of Veterans' Appeals (Board) in July 2019. With great regret, the Board finds that further development is necessary prior to adjudication of the Veteran's claim on appeal. The Board finds that a new medical opinion must be obtained. The Veteran contends that his hypertension is due to his conceded exposure to herbicides. Hypertension is not a disability presumptively associated with herbicide exposure. 38 C.F.R. § 3.309(e). However, the National Academy of Sciences (NAS) has placed hypertension in the category of "limited or suggestive evidence of an association" with exposure to herbicides. See e.g., Health Effects Not Associated with Exposure to Certain Herbicide Agents, 75 Fed. Reg. 32,540, 32,549 (June 8, 2010) ("In Update 2006, NAS concluded that there was 'limited or suggestive evidence of an association between exposure to the compounds of interest and hypertension.'"); Health Outcomes Not Associated With Exposure to Certain Herbicide Agents; Veterans and Agent Orange: Update 2008, 75 Fed. Reg. 81,332, 81,333 (December 27, 2010) (NAS, in 2008, categorized certain health outcomes, including hypertension, to have "'limited or suggestive evidence of an association.' This category is defined to mean that evidence suggests an association between exposure to herbicides and the outcome, but a firm conclusion is limited because chance, bias, and confounding could not be ruled out with confidence."). This was reiterated again in Update 2010. See Determinations Concerning Illnesses Discussed in National Academy of Sciences Report: Veterans and Agent Orange: Update 2010, 77 Fed. Reg. 47,924, 47,926 (Aug. 10, 2012). Based upon these findings, an opinion is necessary regarding a possible etiological relationship between the Veteran's exposure to herbicides during his active service and his current diagnosis of hypertension. The Veteran was afforded a VA examination in February 2020. Here the examiner confirmed a diagnosis of hypertension. The examiner provided negative direct nexus, negative secondary nexus, and negative aggravation opinions. Regarding the direct nexus opinion, the examiner stated that the Veteran's hypertension was diagnosed after he was discharged from the service, so it is not service connected. This opinion is inadequate for the following reasons. First, the opinion is a conclusory statement with no supporting rationale. Secondly, the opinion does not explain why the Veteran's current disability is unrelated to any event or symptoms that he may have experienced in-service. Third, this opinion does not address the Veteran's claim that his hypertension is related to his conceded in-service herbicide exposure. Regarding the examiner's secondary nexus opinion, the examiner's opinion is inadequate for the following reasons. The examiner stated that the Veteran's hypertension was not due to or aggravated by the Veteran's diabetes mellitus. The examiner's supporting rationale was that the Veteran was diagnosed with essential hypertension, meaning there is no known etiology for his condition. While the examiner does state that there is no known etiology, the examiner does not explain why the Veteran's diabetes mellitus is not the cause. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination before an appropriate physician to determine the etiology of any blood pressure disability, to hypertension. The examiner must review the record, to include service treatment records, private treatment records, lay statements, and the Veteran's statements. The examiner must also consideration the Veteran's documented medical history, assertions, and reported symptoms. All necessary tests and studies should be completed, and all clinical findings reported in detail. The examiner must provide an opinion as to whether it is at least as likely as not (i.e., at least 50 percent probable) that any identified blood pressure disorder(s), to include hypertension, manifested during, or as a result of, active military service, to include his presumed herbicide exposure. The examiner is advised to consider the NAS Updates which concluded that there was "limited or suggestive evidence of an association" between hypertension and herbicide exposure. It is not sufficient to conclude that the Veteran's hypertension is not caused by herbicide exposure by stating that hypertension is not listed in VA regulations as presumptively service-connected. If not, the physician should state a medical opinion with respect to any identified blood pressure disorder(s), to include hypertension, present during the period of the claim, as to whether it is at least as likely as not (i.e., at least 50 percent probable) that the blood pressure disorder was caused or permanently worsened by the Veteran's service-connected diabetes mellitus, type II. If the physician believes that a blood pressure disorder was permanently worsened by the service-connected diabetes mellitus, type II, the physician should attempt to identify the baseline level of disability that existed prior to the onset of aggravation and the extent of disability that is attributable to aggravation. In providing the opinion, the examiner must discuss the contemporaneous VA and private diagnoses of hypertension. For purposes of the opinions, the examiner should assume that the Veteran is a credible historian. A complete rationale for all opinions offered must be provided. If the examiner is unable to provide any required opinion, the examiner should fully explain why this is the case. Likewise, if the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. L. BARSTOW Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Lent, Edward 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.