Citation Nr: 21006060 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 13-30 984A DATE: February 3, 2021 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for erectile dysfunction is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1967 to December 1968, including service in the Republic of Vietnam. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a June 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Board previously remanded the issues of the sleep apnea, hypertension, and erectile dysfunction in June 2015, February 2018 and April 2020. 1. Hypertension In April 2020, the Board remanded this claim to obtain an addendum opinion addressing service connection for hypertension due to herbicide agent exposure. The examiner was specifically directed to address the National Academy of Sciences update which concluded that there is suggestive evidence that exposure to Agent Orange and other herbicides is associated with an increased chance of developing hypertension. See December 2015 Veteran correspondence; see also July 2007 article received by VA January 2013. The record contains VA opinions on the matter dated in September 2012, September 2015, November 2015 and June 2019 which the Board previously found inadequate as they are supported by insufficient rationales. See June 2015 and February 2018 Board decision; see also April 2020 Board remand. Pursuant to the Board’s April 2020 remand, an addendum was obtained in May 2020. The examiner reviewed the evidence opined that the Veteran’s hypertension was less likely as not related to service, to include presumed Agent Orange exposure, as he searched the literature and was not able to any medical research to support a correlation between that of HTN and Agent Orange. He stated that when reviewing the list of Agent Orange causing conditions, the VA has not recognized HTN as a presumptive disease associated with its exposure at this time. The examiner did not include the NAS update in the section of evidence comments. An addendum must be obtained addressing the NAS update and providing an opinion based on medical expertise, not the VA's regulations regarding presumptive service connection. Stegall v. West, 11 Vet. App. 268, 271 (1998); Barr v. Nicholson, 21 Vet. App. 303 (2007). 2. Sleep apnea 3. Erectile dysfunction The Veteran seeks service connection for sleep apnea. In part, the Veteran contends that sleep apnea developed due to medication to control hypertension. See December 2015 Veteran correspondence. The Veteran also seeks service connection for erectile dysfunction, to include as secondary to service-connected diabetes mellitus. See September 2012 and December 2015 correspondence. The evidence of record includes a September 2012 VA examination and report that noted a diagnosis of erectile dysfunction. In that report, the examiner indicated that the Veteran's erectile dysfunction appears to be multifactorial as the Veteran is on multiple medications and has conditions, including a longstanding history of hypertension. This evidence raises a secondary theory of entitlement as it pertains to hypertension. Because a decision on the issue of hypertension could significantly impact a decision on the issues of service connection for sleep apnea and erectile dysfunction, the issues are inextricably intertwined. Thus, a remand of the claims for sleep apnea and erectile dysfunction is required. The matters are REMANDED for the following action: 1. Pursuant to 38 U.S.C. § 5109, obtain an advisory medical opinion from an independent medical expert regarding whether the Veteran's hypertension is at least as likely as not related to service, to include presumed Agent Orange or other herbicide agent exposure in service. In offering such opinion, the examiner should consider the fact that the NAS IOM upgraded hypertension from its previous classification in the category of "limited or suggestive" evidence of an association with exposure to Agent Orange to the category of "sufficient" evidence of an association in Update 11 (2018). According to NAS, "[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and herbicide exposure. (Continued on the next page)   A complete rationale for the requested opinion should be provided. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, he or she must explain why this is so. 2. Thereafter, readjudicate the three service connection claims on appeal. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Nadia Kamal, 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.