Citation Nr: 21005498 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 20-12 105 DATE: February 1, 2021 REMANDED Entitlement to service connection for hypertension, to include on a secondary basis and/or as due to herbicide agents exposure, is remanded. Entitlement to service connection for a heart murmur, to include on a secondary basis, is remanded. Entitlement to service connection for restless leg syndrome, to include on a secondary basis and/or as due to herbicide agents exposure, is remanded. REASONS FOR REMAND The Veteran served on active duty in the Army from September 1965 to July 1967, to include service in the Republic of Vietnam. In October 2020, he testified at a virtual hearing before the undersigned. A transcript is associated with the claims file. At the hearing, the record was held open 60 days for the submission of additional evidence. However, no additional evidence has been received. After a thorough review of the record, the Board finds that remand is necessary to ensure due process is followed and there is a complete record upon which to decide the Veteran’s claims. 38 U.S.C. § 5103; 38 C.F.R. § 3.159. Hypertension The Veteran contends, in pertinent part, that his current hypertension is due to his exposure to herbicide agents in service. See March 2020 VA Form 9, and October 2020 Hearing transcript. The Veteran’s records document that he had active duty service in the Republic of Vietnam; therefore, his exposure to herbicide agents (Agent Orange) in service is recognized. See 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a). Hypertension, however, is not one of the diseases listed as being associated with herbicide agents exposure under 38 C.F.R. § 3.309(e). Nevertheless, the Veteran is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). In this regard, the Board notes that the National Academy of Sciences (NAS) in the Agent Orange Update 2018 moved hypertension to the category of “sufficient” evidence of an association from its previous classification in the “limited or suggestive” category. Additionally, the Veteran submitted an April 2019 VA treatment record in support of his claim. In that treatment record, his VA treating physician opined that there was a greater than 50 percent chance that his hypertension was secondary to Agent Orange exposure during his service in the Republic of Vietnam. Unfortunately, the VA treating physician’s medical opinion is conclusory and without any adequate rationale. As explained to the Veteran at the October 2020 Board hearing, any opinion submitted must be one that is well explained with a rationale that supports the conclusion; it cannot be a conclusion only. While the April 2019 medical opinion is insufficient to adjudicate the Veteran’s claim at this time, it does trigger VA’s duty to assist to obtain a VA medical opinion that addresses this question. See McLendon v. Nicholson, 20 Vet. App. 79, 81-84 (2006). Notably, although the Veteran was provided a VA examination in October 2017, it only addressed the question of secondary service connection and did not address whether the Veteran’s hypertension is related to his in-service exposure to herbicide agents. Heart Murmur The Veteran maintains that he has a heart murmur secondary to his service-connected coronary artery disease. See September 2017 VA Form 21-526EZ, and October 2020 hearing transcript. VA treatment records dated in 2018 and 2019 note the presence of a heart murmur. The evidence of record is unclear as to whether the Veteran has a heart murmur that is a symptom of his service-connected coronary artery disease or a standalone diagnosis. Accordingly, on remand, a VA examination and clarifying opinion should be obtained. See McLendon v. Nicholson, 20 Vet. App. 79, 81-84 (2006). Restless Leg Syndrome An October 2017 VA Peripheral Nerves Conditions Disability Benefits Questionnaire (DBQ) noted that the Veteran has diagnoses of restless leg syndrome. While the examiner opined that this disability was not due to or aggravated by service-connected coronary artery disease, no opinion was provided as to whether restless leg syndrome was caused by the Veteran’s presumed exposure to certain herbicide agents during his service in Vietnam. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Accordingly, remand to obtain an addendum opinion is required. See McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). The matters are REMANDED for the following action: 1. Obtain a VA examination and opinion from an appropriate examiner to determine the nature and etiology of any current or recent heart murmur. The claims file (including a copy of this remand) must be provided to and reviewed by the examiner as part of the examination. All indicated tests should be accomplished and all clinical findings reported in detail. a) The examiner must identify whether the Veteran’s heart murmur is a symptom of his service-connected coronary artery disease or whether it is a separate disability; b) If the examiner finds that heart murmur is a separate disability, the examiner should opine as to whether it is at least as likely as not (i.e., 50 percent probability or greater) that the murmur had its onset in service, is otherwise related to service, or was caused or aggravated by the Veteran’s service-connected coronary artery disease. For the purposes of secondary service connection, the examiner is advised that aggravation is defined as “any increase in disability.” See Allen v. Brown, 7 Vet. App. 439, 448 (1995). If aggravation is found, the examiner should also state, to the extent possible, the baseline level of disability prior to aggravation. A rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 2. Obtain VA medical opinions as to the etiology of the Veteran’s hypertension and restless leg syndrome. The examiner must opine whether either disability is at least as likely as not related to an in-service injury, event, or disease, including the Veteran’s in-service exposure to certain herbicide agents. If the examiner determines that any requested opinion may not be provided without a physical examination of the Veteran, then such should be scheduled. A rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. R. Fletcher, 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.