Citation Nr: 21072912 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 16-16 328 DATE: December 6, 2021 REMANDED Entitlement to service connection for a skin disability, to include as due to exposure to herbicides is remanded. Entitlement to service connection for hypertension, to include as secondary to a service-connected disability and/or exposure to herbicides is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1964 to August 1968, to include service in the Republic of Vietnam. This case has been before the Board multiple times, most recently in June 2021 when it was remanded for additional developments. There has not been substantial compliance with the remand directives and the claim must be remanded again. Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for a skin disability, to include as due to exposure to herbicides is remanded. The claim must be remanded again because the September 2021 VA addendum opinion obtained in accordance with the June 2021 remand is inadequate. The Board specifically directed the examiner to consider and discuss as necessary the Veteran's in-service treatment for skin conditions. The September 2021 VA examiner said that there were no skin or rash complaints documented during his active duty service. However, this opinion is based on an inaccurate factual basis. The Veteran's service treatment records show he was treated for rashes during service, in July 1965 and September 1965. Additionally, the Board directed the examiner to provide nexus opinions on all diagnosed skin disorders. The Board specifically identified diagnoses of seborrheic dermatitis, tinea versicolor, and actinic keratitis. The September 2021 VA examiner found that the Veteran did not have current diagnoses of tinea versicolor or actinic keratosis and did not provide etiology opinions. The Board notes that service connection may be granted even though the disability resolves prior to the adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). Accordingly, a new opinion is necessary. Entitlement to service connection for hypertension, to include as secondary to a service-connected disability and/or exposure to herbicides is remanded. The claim must be remanded again because the August 2021 VA examination is inadequate. The examiner provided a negative nexus opinion as to herbicide exposure and as secondary to service-connected PTSD based on a rationale that the Veteran had essential hypertension which was considered idiopathic and without a specific etiology. However, the examiner failed to indicate why this would preclude the possibility of his hypertension being etiologically related to his active service or caused or aggravated by his service-connected PTSD. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate provider (with examination or telehealth interview, review of the record, etc., if needed) on the likely etiology of the Veteran's skin disability. Copies of all pertinent records should be made available to the examiner for review. The examiner should answer the following: (a) Identify all skin disorders diagnosed since May 2011, to include seborrheic dermatitis, tinea versicolor, and actinic keratosis. (b) For each diagnosed skin disorder, to include seborrheic dermatitis, tinea versicolor, and actinic keratosis, is it at least as likely as not related to an in-service injury, event, or disease, to include his presumed exposure to herbicides and/or reported exposure to chemicals at Camp Lejeune and Camp Garcia? Why or why not? The examiner must consider and discuss as necessary the Veteran's documented in-service treatment for skin conditions in July 1965 and September 1965. The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. If an opinion cannot be provided, the examiner should indicate why. 2. Obtain an addendum opinion from an appropriate provider, to determine the nature and likely etiology of his diagnosed hypertension. Copies of all pertinent records must be made available to the examiner for review. The examiner should answer the following: (a) Is it at least as likely as not that the Veteran's diagnosed hypertension had its onset in service, manifested within one year of separation from service in August 1968, or is otherwise related to any incident of the Veteran's active duty service, specifically to include due to herbicide exposure? Why or why not? In providing the opinion, the examiner must specifically address the National Academy of Sciences (NAS) Veterans and Agent Orange Updates, to include in 2018, which stated that there was "sufficient" evidence of an association between hypertension and herbicide exposure. The examiner must discuss whether they find the NAS Updates to be persuasive and weigh the relative risks presented by the Veteran's presumed Agent Orange exposure and other relevant factors. Although VA has not determined that hypertension qualifies for presumptive service connection based on herbicide exposure, this does not preclude a nexus to service. Instead the examiner must consider all pertinent evidence, and offer an opinion as to whether the Veteran's hypertension is due to such exposure. (b) If the answer to (a) is no, is it at least as likely as not that any of the Veteran's hypertension is caused or aggravated (defined as any increase in disability) by his service-connected PTSD? Why or why not? The examiner should consider and discuss as necessary the VA material suggesting an association between PTSD and hypertension. See Presumptions of Service Connection for Diseases Associated with Service Involving Detention or Internment as a Prisoner of War, 70 Fed. Reg. 37040 (June 28, 2005); Presumptions of Service Connection for Diseases Associated with Service Involving Detention or Internment as a Prisoner of War, 69 Fed. Reg. 60083 (Oct. 7, 2004). The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. If an opinion cannot be provided, the examiner should indicate why. 3. Confirm that the VA medical opinion provided comports with this remand, specifically that the standard for the secondary aggravation opinion is any increase in disability, not the standard of beyond the natural progression as noted on the examination form itself. If not, get an addendum. M.E. Larkin Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Eric Struening 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.