Citation Nr: 21008984 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 16-34 129 DATE: February 18, 2021 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for left and right eye disorders is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1964 to January 1985. He served honorably in the U.S. Navy, including service in the Republic of Vietnam during the Vietnam era. The Board thanks the Veteran for his service to our country. The Veteran testified before the undersigned at a Board videoconference hearing in April 2019. A transcript of the hearing is of record. The Board previously remanded this case in July 2019 and August 2020 for additional development. The case has now returned to the Board for further appellate review. 1. Entitlement to service connection for hypertension is remanded. 2. Entitlement to service connection for left and right eye disorders is remanded. A remand of the issues is necessary to associate federal medical records with the claims file. In the August 2020 remand, the Board requested that relevant records from Naval Medical Center San Diego (NMCSD) be associated with the Veteran’s claims file as there was evidence of record that the Veteran had been treated by its cardiology department; records from the facility were associated with the record later that month. However, the records do not include a June 5, 2007 NMCSD record noted in a July 2018 VA examination report which was again referenced in a September 2020 VA addendum opinion. The medical providers noted these records were viewed in “JLV”, an apparent reference to the Joint Legacy Viewer. Additionally, in an October 2020 VA addendum opinion regarding the Veteran’s eye disorders, the clinician referenced November 2008 and March 2011 NMCSD notes in the evidence review and again in the opinion; however, these are also not of record. As there is evidence of outstanding federal medical records which are not included in the benefits file, a remand of the issues is necessary. A remand is additionally necessary for an addendum opinion as to the nature and etiology of the Veteran’s hypertension. In the September 2020 addendum opinion, the clinician concluded that the Veteran’s hypertension is less likely than not related to presumed herbicide agent exposure as the National Academy of Science’s (NAS) Veterans and Agent Orange Update 11 (2018) shows an association between herbicide agent exposure and the occurrence of hypertension; this does not necessarily imply that exposure causes the disorder but that they are frequently seen together. The clinician concluded that evidence of an association does not imply that exposure causes hypertension and identified various risk factors for primary hypertension. In addition to the fact that the rationale does not demonstrate that the Veteran’s disorder is less likely than not related to herbicide agent exposure, the Board takes judicial notice that the charge to the Update 11 committee was to determine, “regarding associations between specific health outcomes and exposure to [chemicals of interest]”: 1) whether a statistical association with herbicide exposure exists; 2) the increased risk of disease among those exposed to herbicides; and 3) whether there exists a plausible biological mechanism or other evidence of a causal relationship between herbicide exposure and the disease. Additionally, with respect to hypertension, Update 11 notes that owing to the frequency of the disorder, “assessing whether there is increased risk with exposure… has been challenging”; however, there are enough new data to move the category of association to sufficient evidence. As this seemingly qualifies the clinician’s conclusion that Update 11 is evidence of comorbidity rather than causation, a remand is necessary. Furthermore, the Board notes that in a February 2018 letter, a private sleep medicine specialist stated that untreated sleep apnea causes significant biological stress to the cardiovascular system, resulting in hypertension, and noted that the Veteran had untreated obstructive sleep apnea. As there is an indication of an association between the Veteran’s hypertension and service-connected sleep apnea, an opinion is necessary as well. The matters are REMANDED for the following action: 1. Please secure for the record (the Veteran’s electronic benefits file) copies of complete updated clinical records (any not already of record) of all VA and non-VA treatment the Veteran has received for the disability on appeal. Please ask the Veteran to provide the releases necessary for VA to secure private treatment records. (a.) In particular, please print and upload into VBMS relevant records in the JLV (Joint Legacy Viewer), including the following records noted to be in the JLV by VA clinicians: i. Records from Balboa Naval Hospital (Naval Medical Center San Diego, and specifically to include a November 5, 2008 record with a Dr. B. and a March 14, 2011 note with a Dr. P. (both referenced in the October 2020 addendum opinion) and a June 5, 2007 note in which Micardis was prescribed. 2. After the actions requested in paragraph 1 are complete, please refer the claim to an appropriate clinician for an opinion as to the nature and etiology of the Veteran’s hypertension. The Veteran’s claims-file must be made available to and reviewed by the clinician. The clinician is requested to opine as to the following: (a.) Is the Veteran’s hypertension at least as likely as not (a 50 percent or greater probability) related to presumed herbicide agent exposure? Please address 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 to the category of “sufficient” evidence. If the rationale is based wholly or in part on a conclusion that evidence of an association between herbicide agent exposure and hypertension does not necessarily imply a causal relationship, the clinician must address the Committee’s Statement of Task which includes determining “the increased risk of the disease among those exposed to herbicides during service in the Republic of Vietnam…” and “whether there exists a plausible biological mechanism or other evidence of a causal relationship between herbicide exposure and the disease” as well as a statement, with respect to hypertension, that while “assessing whether there is increased risk with exposure… has been challenging,” the committee concluded that there are enough new data to move the category of association to sufficient evidence (https://www.nap.edu/catalog/25137/veterans-and-agent-orange-update-11-2018, pages 20 Box 1-1 and 496, respectively). (b.) Is the Veteran’s hypertension at least as likely as not (a 50 percent or greater probability) caused by service-connected obstructive sleep apnea? Please address a February 22, 2018 letter by a Dr. S., a Diplomate of the American Board of Sleep Medicine, stating that untreated sleep apnea causes significant biological stress to the cardiovascular system, resulting in hypertension, and that the Veteran had untreated obstructive sleep apnea (Medical Treatment Record – Non-Government Facility file associated with the record on April 25, 2018). (c.) Is the Veteran’s hypertension at least as likely as not (a 50 percent or greater probability) aggravated by service-connected obstructive sleep apnea? The clinician must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. The clinician should take into consideration that the Veteran is competent to report in service and post-service symptom experiences; other witnesses are competent to report observable symptoms. If the clinician cannot provide an opinion without resorting to speculation, the clinician should provide an   explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Vashaw, 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.