Citation Nr: 21005700 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 13-12 525 DATE: February 2, 2021 REMANDED Service connection for a heart disability, to include diagnosed sinus bradycardia, first-degree atrioventricular (AV) block, and mild concentric left ventricular hypertrophy (LVH) is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1956 to March 1978. This matter is before the Board of Veterans Appeals (Board) on appeal from a June 2011 rating decision. In December 2015 and March 2020, the Board remanded the case for additional development. Service connection for a heart disability, to include diagnosed sinus bradycardia, first-degree atrioventricular (AV) block, and mild concentric left ventricular hypertrophy (LVH) is remanded. Despite the additional and regrettable delay, a remand is needed to obtain an addendum medical opinion pursuant to the specific directives below. The VA medical opinion provided appears to suggest that herbicide agent exposure is a contributing factor to the Veteran’s hypertension, but it is unclear from the opinion whether herbicide agent exposure was outweighed by the Veteran’s other risk factors or is just another risk factor in a long list of risk factors for development of hypertension. Additionally, the examiner opines that obesity and being overweight is the Veteran’s most significant risk factor and goes on to note the Veteran was discharged and refused re-enlistment because he was significantly overweight in service. Finally, it is unclear from the signature block of the opinion whether the original examiner wrote or simply signed off on the opinion provided by another examiner (not a VA cardiologist). For these reasons, a new addendum opinion must be obtained. The matters are REMANDED for the following action: 1. Please note that this Veteran’s case has been advanced on the docket and, by law, ALL remanded claims must be processed expeditiously. 2. Obtain an addendum medical opinion from the original May 2019 examiner or a VA cardiologist if the original examiner is unavailable to determine the nature and likely cause of the Veteran’s hypertension/heart disability. The examiner should review the claims file (including this remand) and note such review was conducted. Based on review of the record, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s hypertension was caused by established exposure to herbicide agents? Please specifically discuss the updated NAS report regarding the relationship between herbicide agent exposure and hypertension. The Board request clarification from the July 2020 addendum medical opinion on whether the examiner was opining that it is at least as likely as not that in-service herbicide agent exposure was a contributing factor to the Veteran’s development of hypertension later in life or not. Additionally, the July 2020 addendum medical opinion appears to suggest that obesity is a substantial factor in the Veteran’s hypertension development and notes that the Veteran was denied re-enlistment due to being overweight. Is the examiner opining that the Veteran’s in-service weight gain contributed to the Veteran’s development of hypertension in 1981 and thus, it is at least as likely as not that the Veteran’s hypertension is directly related to service? Any medical opinion that dismisses a causal relationship between the Veteran’s hypertension and herbicide exposure solely because hypertension is not a condition entitled to PRESUMPTIVE service connection under applicable laws and regulations will be inadequate, by law because a veteran may establish direct service connection with supporting medical evidence even when presumptive service connection does not apply. [CONTINUED ON NEXT PAGE] A detailed explanation (rationale) is required for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested.) VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Williams, 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.