Citation Nr: 21007355 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 20-03 177 DATE: February 9, 2021 REMANDED Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran, who is the appellant in this case, served on active duty from May 1966 to May 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2018 rating decision by the Regional Office (RO) of the Department of Veterans Affairs (VA). After the issuance of the December 2019 statement of the case (SOC), but prior to certification of the appeal to the Board, the Veteran submitted additional articles discussing a possible link between hypertension and Agent Orange in January 2020. The Board finds this evidence is duplicative of articles submitted by the Veteran in April 2019 and thus these findings have already been considered by the AOJ in the December 2019 SOC. Cf. 38 C.F.R. §§ 19.31(b)(1), 19.37(a). Nonetheless, given that the Board is remanding the claim, the AOJ will have opportunity to review the additional evidence received. VA is required to provide an examination or obtain a medical opinion in a claim for service connection when the record contains competent evidence that the claimant has a current disability or persistent or recurrent symptoms of disability, the record indicates that the disability or symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159; McLendon v. Nicholson, 20 Vet. App. 79 (2006). A June 2018 VA Disability Benefits Questionnaire reflects a diagnosis of hypertension with an onset date of May 2018. The RO has conceded the Veteran’s exposure to herbicide agents due to his service in Vietnam. The Veteran’s DD Form 214 reflects the Veteran was awarded the Vietnam Service Medal, Vietnam Campaign Medal with 2 overseas Bars and the service treatment records (STRs) confirm that the Veteran served in Vietnam during 1967 to 1968. Thus, the Veteran’s confirmed active service in Vietnam entitles him to the presumption of exposure to an herbicide agent during such active service. Although hypertension is not one of the specified diseases for which service connection may be presumed based upon the Veteran’s presumed exposure to herbicides during his service in the Republic of Vietnam, the Board notes the recent publication of Veterans and Agent Orange: Update 11 (2018), published by the National Academy of Science (NAS), found “sufficient evidence” of an association between hypertension and exposure to herbicide agents such as Agent Orange. This publication upgraded hypertension’s previous classification in the category of “limited or suggestive” evidence of an association to the category of “sufficient” evidence of an association. 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. Notably, the Veteran has also submitted several articles indicating hypertension and high blood pressure may be linked to Agent Orange exposure in April 2019 and again in January 2020. As there is no opinion addressing whether the Veteran’s hypertension is at least as likely as not related to his presumed exposure to herbicide agents, the Board finds it is necessary to remand this issue to obtain a medical opinion, addressing the most recent scientific evidence, as well as the articles submitted by the Veteran. The matter is REMANDED for the following action: Obtain a VA medical opinion from an appropriately qualified physician, to assist in determining the nature and etiology of the Veteran’s hypertension. If the examiner believes that an in-person examination is necessary to provide an informed opinion, an examination should be scheduled. To assist the examiner in rendering the requested opinion, the Board provides the following relevant evidence, with citations to the record, where appropriate: • The Veteran served on active duty from May 1966 to May 1968 with one year of service in Vietnam. • The Veteran is presumed to have been exposed to herbicide agents while in Vietnam. • The Veteran has a diagnosis of hypertension and claims it was caused by his exposure to herbicide agents in Vietnam. • The Veteran’s service treatment records do not document a diagnosis of hypertension. The May 1968 Report of Medical Examination from service discharge shows blood pressure was 120/70. See VBMS entry with document type, “STR – Medical,” receipt date 12/06/1968, with “#1” in the subject field, p. 8-9 (blood pressure is at item # 57). • In the corresponding May 1968 Report of Medical History from service discharge, the Veteran denied a history of high or low blood pressure. See VBMS entry with document type, “STR – Medical,” receipt date 12/06/1968, with “#2” in the subject field, p. 11 (high or low blood pressure is listed in item # 20, middle column). • An April 2018 Diabetes Mellitus Disability Benefits Questionnaire shows a diagnosis of essential hypertension, which date of diagnosis is written “2015.” See VBMS entry with document type, “VA Examination,” receipt date 04/04/2018, p. 2. • The Veteran is service connected for type II diabetes mellitus, but a medical professional determined that the Veteran’s hypertension was not due to the type II diabetes mellitus because there would need to be evidence of diabetic renal dysfunction to diagnose hypertension due to diabetes mellitus and that laboratory findings have shown a normal renal function at that time, which was in 2018. See VBMS entry with document type, “C&P Exam,” receipt date 06/06/2018, with “DBQ MEDICAL OPINION” in the subject field, p. 2. • In a 2018 update, the National Academy of Science (NAS) Institute of Medicine found “limited or suggestive” evidence of a relationship between exposure to herbicide agents and the development of hypertension. 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. See https://www.nap.edu/read/25137/chapter/1. Hypertension is discussed beginning on page 487, which page number may be entered where it says, “Page # of 716” at the top where it says, “Contents.” (Enter page number where “#” is shown.) • Articles addressing the NAS study can be found in VBMS entry with document type, “Web / HTML Documents,” receipt date 04/07/2019. • There are other articles that the Veteran has submitted, but all of them surround the NAS study findings and are not medical treatises. • The examiner’s review of the record is NOT restricted to the evidence listed above. This list is provided in an effort to assist the examiner in locating potentially relevant evidence. Following review of all available evidence, to include all evidence obtained pursuant to the remand, the medical professional should offer an opinion as to 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 his presumed exposure to herbicide agents during active duty? In rendering the above opinion, the examiner must specifically comment on the National Academy of Science’s Agent Orange: Update 11 (2018), which upgrades hypertension from the category of “limited or suggestive” evidence of an association with herbicide exposure the category of “sufficient” evidence; and whether the Veteran has other risk factors that are more likely the cause of hypertension given his complete medical history. A full rationale, including reference to supporting clinical data and/or medical literature as deemed appropriate, must be provided for all medical opinions given. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sarah Campbell, 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.