Citation Nr: 21074043 Decision Date: 12/14/21 Archive Date: 12/14/21 DOCKET NO. 17-41 264 DATE: December 14, 2021 REMANDED Entitlement to service connection for hypertension, to include as due to exposure to herbicide agents and/or secondary to service-connected diabetes mellitus type II (DM), is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from June 1968 to December 1969. VA has conceded the Veteran's exposure to herbicide agents in service. See VA Memo (June 2013). The record reflects the Veteran is in receipt of a statutory 100 percent combined rating and found to be permanently and totally disabled, effective August 31, 2012. This appeal comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the claim in December 2019 and September 2021 for further development. Entitlement to service connection for hypertension is remanded. The Veteran contends that his hypertension is due to his in-service herbicide exposure. The Veteran, alternatively, contends that his hypertension is secondary to his service-connected DM, type II. See VA Form 9 (August 2017). Unfortunately, the Board finds that remand is required for an adequate addendum opinion that complies with its prior remand directives. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). While hypertension is not currently one of the enumerated medical conditions for which service connection can be granted on a presumptive basis, that does not preclude the Veteran from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039, 1041-42 (Fed. Cir. 1994). The National Academies of Sciences, Engineering and Medicine (NAS) concluded that there is sufficient epidemiologic evidence to conclude that there is a "positive association" between hypertension and herbicide exposure. A contract medical opinion dated in October 2021, obtained by VA, concluded that it was less likely than not that the Veteran developed hypertension due to his presumed herbicide agent exposure. The rationale was that it more likely developed because of the Veteran's lifestyle choices and that, although NAS suggests a possible association between herbicide exposure and hypertension, "there is no presumption of connection." The examiner stated that the Veteran smoked 2 packs of cigarettes per day for 15 years which is a strong risk factor for developing hypertension. Furthermore, the examiner stated the Veteran was exposed to second-hand smoke because his wife continued to smoke after he stopped in the 1980s. The Board finds that the October 2021 medical opinion is inadequate. First, it does not explain why the Veteran's lifestyle choices and/or smoking or exposure to second-hand smoke is more likely the cause of his hypertension. It is also noted that a medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record. See Stefl v. Nicholson, 21Vet. App.102, 124-25. A "medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two." Nieves-Rodriguez v. Peake, 22Vet. App.295, 301 (2008). Second, the opinion relies inappropriately on the fact that hypertension is not included on the list of diseases presumptively associated with herbicide agent exposure, when a link may be established to service on a direct (rather than presumptive) basis. See Combee, supra. Lastly, the Board notes that, in his substantive appeal, the Veteran alternatively claims that his hypertension is secondary to his service-connected DM, type II. See VA Form 9 (August 2017). Although an August 2013 VA DM examination report reflects that hypertension was not determined to be a complication of DM, a December 2019 VA medical opinion noted the Veteran has several risk factors for the development of hypertension, including among other things, DM, type II. The examination report also indicates the Veteran is diagnosed with chronic kidney disease, stage IV. Here, VA had not obtained a medical opinion on the matter of secondary service connection and the Board finds there is sufficient evidence of record to trigger VA's duty to assist in obtaining a medical opinion. Given the discussion above, remand is required to obtain an adequate medical opinion as to whether the Veteran's hypertension is directly related to his exposure to herbicides during service and whether it is secondary to his service-connected DM, II. The matter is REMANDED for the following action: 1. Obtain an addendum opinion to the October 2021 medical opinion, from an appropriate clinician, regarding the etiology of the Veteran's hypertension. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. A complete explanation is required for discounting and/or rejecting the Veteran's assertion that his hypertension is due to his in-service herbicide exposure and/or secondary to his diabetes mellitus, type II. If another etiology, such as a history of heavy smoking, is the more likely cause of the Veteran's hypertension, the clinician must provide a complete explanation of his or her reasoning specific to the facts of the Veteran's case. The opinion should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). The clinician must opine on: Direct Service Connection (a.) Whether hypertension at least as likely as not (1) began during active service, or (2) manifested to a compensable degree within one year after active service, or (3) is related to an in-service injury, event, or disease, to include conceded in-service exposure to herbicide agents (regardless of the fact it is not a disease enumerated as presumptively associated with herbicide agent exposure under VA regulations at this time). Consider and discuss the NAS finding that there is sufficient epidemiological evidence of a positive association between exposure to Agent Orange and hypertension; and explain whether the positive association when considered in light of the Veteran's clinical history and exposure to herbicide agents establishes, at least as likely as not that hypertension etiologically related to herbicide agents. If another etiology is more likely the cause, this must be fully explained. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints/findings. NOTE (2): If any medical history is rejected or discounted, a complete explanation is required. NOTE (3): An adequate medical opinion may not be predicated solely on medical literature without discussing it vis-à-vis facts specific to the Veteran. NOTE (4): An adequate medical opinion may not be predicated on the absence of the claimed condition in the VA regulatory list of diseases enumerated as presumptively associated with herbicide agent exposure. Secondary Service Connection (a.) Whether the Veteran's hypertension is at least as likely as not (1) proximately due to a service-connected disability, including diabetes mellitus, type II, or (2) aggravated beyond its natural progression by a service-connected disability, including diabetes mellitus, type II. It is noted that the Veteran has been diagnosed with chronic kidney disease which is not a service-connected disability at this time. 2. Ensure that the medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include 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. 3. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Krunic, 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.