Citation Nr: A21020499 Decision Date: 12/23/21 Archive Date: 12/23/21 DOCKET NO. 200506-82525 DATE: December 23, 2021 REMANDED Entitlement to service connection for pulmonary hypertension, to include as secondary to PTSD, is remanded. Entitlement to service connection for clear cell renal cell carcinoma (renal cancer), to include as secondary to PTSD is remanded. REASONS FOR REMAND The Veteran had active service from December 1968 to July 1971. Unfortunately, the Veteran died on January [REDACTED], 2021. The Veteran's spouse is now recognized as the Appellant. In the May 2020 VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the agency of original jurisdiction (AOJ) decision on appeal. 38 C.F.R. § 20.301. Evidence was added to the claims file during a period of time when new evidence was not allowed. As the Board is remanding the claims of service connection for pulmonary hypertension and renal cancer for further development, this additional evidence will be considered by the RO in the adjudication of those claims. 1. Entitlement to service connection for pulmonary hypertension to include as secondary to Agent Orange exposure and/or PTSD is remanded. 2. Entitlement to service connection for clear cell renal cell carcinoma (renal cancer), to include as secondary to Agent Orange exposure and/or PTSD is remanded. The Veteran contended that his pulmonary hypertension and clear cell renal cell carcinoma (renal cancer), were related to his active service. Specifically, the Veteran contended that these conditions were caused his exposure to Agent Orange. In the alternative, the Veteran contended that these conditions were secondary to his service-connected PTSD. The Veteran had confirmed service in in the Republic of Vietnam for the period July 30, 1969 to January 13, 1970, and it is conceded that the Veteran was exposed to Agent Orange. The Veteran also had a confirmed diagnosis of clear cell renal cell carcinoma status post right nephrectomy. See November 2019 VA examination. The issues of entitlement to service connection for the Veteran's pulmonary hypertension and clear cell renal cell carcinoma (renal cancer) are remanded to correct duty to assist errors that occurred prior to the April 2020 rating decision on appeal. The error was that the AOJ did not secure VA opinions for secondary service connection for either pulmonary hypertension or renal cancer prior to making determinations. In addition, the mild pulmonary hypertension was noted within the Veteran's treatment records, and then the private medical examiner's medical opinion indicated that this condition was related to the Veteran's military service which triggered VA's duty to obtain a VA medical opinion. See McLendon v. Nicholson, 20 Vet. App. 79, 81-83 (2006). The October 2019 private examiner opined that that the Veteran's clear cell renal cell carcinoma (renal cancer) was more likely than not (more than 50% probability) proximately due to or the result of the Veteran's exposure to Agent Orange, secondary to obesity, which was caused by the Veteran's service-connected PTSD. The examiner did not provide an adequate rationale as to why the Veteran's PTSD caused the Veteran's obesity but instead used conclusionary statements. The Board acknowledges that the examiner cited studies regarding the correlation between the two, but the Board did not find the examiner adequately explained the relationship between the Veteran's obesity and the Veteran's PTSD. In addition, while the examiner provided a long analysis of how dioxins can cause cancer, and the examiner noted that tobacco has dioxin in it, the examiner did not explain why smoking was "significantly less probable" in playing a significant causal role in the Veteran's development of renal cancer. In November 2019, the VA secured an addendum opinion for the Veteran's clear cell renal cell carcinoma (renal cancer) condition. The examiner opined that the Veteran's clear cell renal cell carcinoma (renal cancer) is less likely than not (less than 50% probability) proximately due to or the result of the Veteran's exposure to Agent Orange. As to the rationale, the examiner explained that there was inadequate/insufficient evidence to determine any association or causation between exposure to AO and renal cancer. The examiner also explained that the Veteran's obesity and tobacco use were risk factors for developing renal cell carcinoma. The examiner did not address the October 2019 private examiner's opinion that opined that the Veteran's renal cancer was secondary to the Veteran's obesity, that was caused by the Veteran's PTSD. In addition, the examiner indicated that the obesity and tobacco were risk factors but did not provide any further analysis. The Board finds that both the October 2019 private medical opinion and the November 2019 VA medical opinion are inadequate for these reasons. Thus, securing addendum medical opinions is necessary prior to adjudication to address the duty to assist errors that occurred prior to the April 2020 rating decision on appeal. The matter is REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician to determine the nature and etiology of the Veteran's pulmonary hypertension and clear cell renal cell carcinoma (renal cancer). The complete claims file to include this remand, must be made available to, and reviewed by, the examiner. 2. The examiner should provide the following medical opinions: (a.) Is it at least as likely as not (at least a 50 percent probability) that the Veteran's pulmonary hypertension is directly related to military service, to include as a result of exposure to herbicides while he was in Vietnam? (b.) Is it at least as likely as not (at least a 50 percent probability) that the Veteran's renal cancer is directly related to military service, to include as a result of exposure to herbicides while he was in Vietnam? The examiner must note and specifically address the relevant conclusions made by the October 2019 private examiner for both (a) and (b). (c.) The examiner must opine whether it is at least as likely as not that the Veteran's pulmonary hypertension (1) proximately due to, or (2) aggravated beyond its natural progression by the Veteran's service-connected PTSD. (d.) The examiner must opine whether it is at least as likely as not that the Veteran's renal cancer (1) proximately due to, or (2) aggravated beyond its natural progression by the Veteran's service-connected PTSD. 3. If the clinician determines that the Veteran's pulmonary hypertension or renal cancer is not directly caused by a service-connected disability, then he or she must also provide an opinion regarding the relationship, if any, between the Veteran's service-connected psychiatric disability; his obesity; his pulmonary hypertension; and renal cancer. The clinician must opine as to the following: (a.) Is it at least as likely as not that the Veteran's service-connected disabilities caused him to become obese? (b.) If so, was the obesity, as a result of the service-connected disabilities, a substantial factor in causing or aggravating the Veteran's pulmonary hypertension or renal cancer? (Continued on the next page) (c.) Would the Veteran's pulmonary hypertension or renal cancer have not occurred but for the obesity caused by the service-connected disabilities? MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Quist Associate 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.