Citation Nr: 21075457 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 16-03 382 DATE: December 20, 2021 REMANDED Entitlement to service connection for hypertension, as secondary to service-connected diabetes, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from September 1975 to August 1967, to include service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). By way of background, the Board initially remanded this matter in June 2019 to the Agency of Original Jurisdiction (AOJ) for additional development. After the case returned, the Board denied the claim in September 2020, and the Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In September 2021, the Court granted a Joint Motion for Remand (JMR) in which the parties agreed to vacate the September 2020 decision and remand the matter to the Board. The Veteran has asserted that his hypertension was caused by his active duty service, to include as secondary to his service-connected diabetes. See January 2016 Substantive Appeal. Alternatively, as recently raised on the record, the Veteran asserts that his hypertension was due to exposure to herbicide agents incurred during his service in the Republic of Vietnam. See September 2021 Correspondence. In the September 2021 JMR, the parties noted that the Veteran had submitted multiple pieces of medical literature in support of his claim, to include an About.com article by Dr. C.W. who stated that the effects caused by hypertension and diabetes mellitus tend to make other disease more likely to occur. In the article, Dr. C.W. also stated that some of the effects of diabetes mellitus include increased fluid volume, increased arterial stiffness, and impaired insulin handling which can increase blood pressure. The Court's JMR noted that it is unclear if the VA medical opinion obtained in March 2020 considered all the relevant medical evidence, to include the article from About.com. Consistent with the JMR, the Board finds that an addendum VA medical opinion should be obtained. Additionally, the Veteran has recently asserted that his hypertension was caused by exposure to herbicide agents as a result of his service in the Republic of Vietnam. Under the law as it now stands, a presumption of service connection based on the Veteran's exposure to Agent Orange cannot be granted because hypertension does not appear on the list of diseases considered presumptively associated with herbicide exposure. 38 C.F.R. § 3.309. However, in addition to the presumptive regulations, a veteran may establish service connection based on exposure to herbicide agents with proof of actual direct causation. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). Thus, an opinion should be obtained addressing whether the Veteran's hypertension was caused by exposure to herbicide agents. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all outstanding treatment records relevant to his hypertension claim. All identified VA records, not currently part of the record, should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken, to include notifying the Veteran of the unavailability of the records. 2. After records development is completed, the claims file should be sent to an appropriate examiner to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the current hypertension onset during service or is otherwise related to an in-service injury, event, or disease, to include as due to exposure to herbicide agents while he served in the Republic of Vietnam. The reviewing physician is advised that "Veterans and Agent Orange: Update 11," published by NAS in 2018 reclassified the possible association between hypertension and exposure to agent orange from "limited or suggestive" to "sufficient." The examiner should also address whether the current hypertension disability is at least as likely as not (a) caused by, or (b) aggravated by (worsened beyond natural progression) service-connected diabetes mellitus, type II. In offering the opinion, the examiner MUST consider all the medical literatures in the record, to include the About.com article by Dr. C.W. who noted that some of the effects of diabetes mellitus include increased fluid volume, increased arterial stiffness, and impaired insulin handling which can increase blood pressure. The need for an examination is left to the discretion of the examiner. A rationale for all opinions offered is requested as adjudicators are precluded from making any medical findings. Katherine Kiemle Buckley Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Mathew 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.