Citation Nr: 21075485 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 16-50 941 DATE: December 20, 2021 REMANDED Entitlement to service connection for hypertension, to include as due to exposure to herbicides and as secondary to his service-connected chronic obstructive pulmonary disease (COPD), or as secondary to his service-connected posttraumatic stress disorder (PTSD). REASONS FOR REMAND The Veteran had active military service in the United States Army from July 1968 to May 1970. He received the Combat Infantryman Badge, among other decorations, for this service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision issued by a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). The Veteran testified before the undersigned at a hearing held in November 2017; a transcript of that hearing is of record. In February 2021, the Board denied service connection for hypertension. The Veteran appealed the Board decision to the United States Court of Appeals for Veterans Claims (Court). In September 2021, the Court granted a Joint Motion for Partial Remand (JMPR), vacating and remanding the issue. 1. Entitlement to service connection for hypertension. The Veteran contends that his current hypertension is causally related to his service in Vietnam, to include as due to herbicide agent exposure, as secondary to his service-connected COPD, or as secondary to his service-connected PTSD. The Veteran has consistently reported that while in Vietnam, he came into regular contact with Agent Orange, and VA has conceded that the Veteran was exposed to herbicide agents during his service in Vietnam. To date, there is no adequate medical opinion that opines on whether the Veteran's hypertension is service-connected. See December 2019 Board remand (finding that the April 2019 VA hypertension etiology medical opinion was inadequate for adjudicating purposes); see also August 2020 Board remand (finding that the February 2020 VA hypertension etiology medical opinion was inadequate for adjudicating purposes). Further, the Board notes that the September 2021 CAVC JMPR opinion found the September 2020 VA Disability Benefits Questionnaire (DBQ) hypertension opinion inadequate. The September 2021 CAVC opinion determined that the September 2020 VA DBQ opinion used the wrong standard when assessing whether the Veteran's hypertension was aggravated by herbicide agent exposure, COPD, and PTSD. The September 2021 CAVC opinion also indicated the September 2020 VA DBQ opinion was inadequate because the examiner failed to consider the Veteran's full medical history and provide adequate rationale to support her conclusions. The Board agrees with the September 2021 CAVC opinion's ruling that the September 2020 VA DBQ opinion is inadequate for adjudicating purposes. Accordingly, as the current record before the Board lacks an adequate nexus opinion or other competent evidence sufficient to determine the etiology of the Veteran's hypertension, the Veteran's claim must be remanded for an addendum medical opinion to determine whether the Veteran's hypertension is related to his active military service and thus entitled to service connection on either a direct or a secondary basis. See Colvin v. Derwinski, 1Vet. App.171, 175 (1991). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Here, the Board finds the September 2020 VA DBQ opinion inadequate for adjudication purposes. An addendum VA medical opinion is necessary with regard to full and fair consideration of the evidence of record for his service connection claim for hypertension. See Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence... is essential for a proper appellate decision"). Although the Board regrets this delay, such a remand is necessary to ensure fair and appropriate adjudication of the Veteran's claim consistent with VA's duties to assist. The matter is REMANDED for the following action: 1. Obtain an addendum medical opinion from a qualified examiner regarding the etiology of the hypertension, to include as due to herbicide agent exposure, as secondary to his service-connected COPD, or as secondary to his service-connected PTSD. The examiner must review the Veteran's claims file, including this remand, and explain the complete rationale for all opinions expressed and conclusions reached. An examination of the Veteran is only necessary if deemed so by the examiner. The VA examiner should offer both an opinion and a complete rationale (citing to supporting clinical data/medical literature as appropriate) for each of the following: Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's hypertension is related to service, to include being caused or aggravated by the presumed in-service herbicide exposure. In so doing, the appropriate examiner MUST specifically comment and discuss: The National Academy of Sciences (NAS) Institute of Medicine, Veterans & Agent Orange: Update 11 (2018): noting an upgrade of hypertension to the "sufficient" category from "limited or suggestive," indicating that "there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and herbicide exposure. The examiner should note that it is inadequate to conclude that hypertension is not related to service simply because it is not on VA's list of presumptive diseases associated with exposure to herbicides. Whether it is at least as likely as not that the Veteran's hypertension was either caused by or aggravated by his service-connected COPD. In so doing, the appropriate examiner MUST specifically comment and discuss the evidence in the record indicating that the Veteran's COPD may be the cause of his inactivity, including: (1) The December 2019 VA palliative care note stating "[the Veteran] continues to report...inability to do [activities] w/o [shortness of breath]"; and (2) The July 2015 VA pulmonary consult note indicating "dyspnea on moderate activity." Whether it is at least as likely as not that the Veteran's hypertension was either caused by or aggravated by his service-connected PTSD. In so doing, the appropriate examiner MUST specifically comment and discuss the following: The April 2019 VA examination report that indicated hypertension and depression share common pathways and it is possible that each disease has an impact on the natural history of the other disease. A thorough rationale should be provided for all opinions expressed, including discussion of the facts of this case and any medical studies or literature relied upon. The examiner should fully articulate a sound reasoning for all conclusions made. If any requested medical opinion cannot be given, the examiner should state the reason(s) why. The entire claims file, including a copy of this REMAND, must be reviewed. H. SEESEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Dourmashkin 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.