Citation Nr: 21009587 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 12-27 073A DATE: February 22, 2021 ORDER Service connection for dermatophytosis also claimed as tinea pedis or tinea cruris, to include as secondary to herbicide exposure, is denied. Service connection for erectile dysfunction (ED), to include as secondary to service-connected coronary artery disease (CAD) and/ or type II diabetes mellitus is granted. Entitlement to a rating in excess of 50 percent prior to December 16, 2019 for service-connected PTSD and in excess of 70 percent thereafter is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted, subject to the regulations governing the award of monetary benefits. REMANDED Entitlement to service connection for hypertension to include as secondary to herbicide exposure, diabetes, and/or service - connected PTSD is remanded. Entitlement to a rating in excess of 60 percent for coronary artery disease status post myocardial infarction w/coronary artery bypass grafting times 5 is remanded. FINDINGS OF FACT 1. The Veteran is not shown to have had a skin disability during the pendency of the instant claim seeking service connection for dermatophytosis also claimed as tinea pedis or tinea cruris. 2. Resolving all reasonable doubt in the Veteran’s favor, his erectile dysfunction (ED) is related to service-connected coronary artery disease (CAD), posttraumatic stress disorder (PTSD) and/ or type II diabetes mellitus. 3. Prior to December 16, 2019 the Veteran’s service-connected PTSD was manifested by symptoms no greater than occupational and social impairment with reduced reliability and productivity; symptoms productive of occupational and social impairment with deficiencies in most areas have not been shown. 4. From December 16, 2019 the Veteran’s service-connected PTSD was manifested by symptoms productive of occupational and social impairment with deficiencies in most areas; total and social impairment have not been shown. 5. Resolving all reasonable doubt in his favor, the Veteran’s service-connected disabilities have rendered him unable to secure and follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for service connection for dermatophytosis also claimed as tinea pedis or tinea cruris, to include as secondary to herbicide exposure have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.102, 3.303, 3.310. 2. The criteria for service connection for erectile dysfunction (ED) secondary to service-connected coronary artery disease (CAD), posttraumatic stress disorder (PTSD), and/ or type II diabetes mellitus have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.102, 3.303, 3.310. 3. For the period prior to December 16, 2019, the criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107(b), 5110; 38 C.F.R. §§ 3.102, 4.130, Diagnostic Code (DC) 9411. 4. For the period from December 16, 2019, a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107(b), 5110; 38 C.F.R. §§ 3.102, 4.130, DC 9411. 5. The criteria for a TDIU are met. 38 U.S.C. § 1155, 5103(a), 5103A, 5107; 38 C.F.R. § 3.102, 3.159, 3.340, 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from April 1968 to April 1970, with verified service in the Republic of Vietnam (Vietnam). He was awarded the Combat Infantryman Badge. These matters are before the Board of Veterans’ Appeals (Board) on appeal from rating decisions dated September 2008 and December 2012 by the Regional Office (RO) of the Department of Veterans Affairs (VA). The claims on appeal were remanded in September 2017 for the Agency of Original Jurisdiction (AOJ) to review new and relevant evidence and April 2019 for the issuance of a supplemental statement of the case (SSOC) and further development respectively. Service Connection Service connection may be established for disability due to disease or injury that was incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. To establish service connection for a claimed disability, there must be evidence of: (i) a present claimed disability; (ii) incurrence or aggravation of a disease or injury in service; (iii) and a causal relationship between the present disability and the disease or injury in service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303 (a). Secondary service connection is warranted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Briefly, the threshold legal requirements for a successful secondary service connection claim are: (1) evidence of a current disability for which secondary service connection is sought; (2) a disability for which service connection has been established; and (3) competent evidence of a nexus between the two. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104, F.3d 1328 (Fed. Cir. 1997). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Pain may, in the absence of a diagnosis or underlying pathology, be considered a current disability under 38 U.S.C. § 1110 if it results in functional impairment of earning capacity. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159 (a)(2). Competent medical evidence is necessary where the determinative question requires medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159 (a)(1). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). 1. Entitlement to service connection for dermatophytosis also claimed as tinea pedis or tinea cruris, to include as secondary to herbicide exposure. The Veteran contends in a May 2008 statement that dermatophytosis, a skin disability, also claimed as tinea pedis or tinea cruris is related to herbicide exposure while serving on active duty in Vietnam. He seeks service connection. A March 2008 VA treatment record noted a diagnosis for tinea pedis. The Veteran was prescribed clotrimazole and advised to dry his toes well. There is no record of complaints or treatment for dermatophytosis, tinea pedis or tinea cruris during the relevant period. In December 2019, the Veteran was afforded a VA skin disease examination. The Veteran reported that while he was diagnosed and treated for tinea cruris and tinea pedis in the past, he is currently asymptomatic. The VA examiner indicated that the Veteran had no skin condition and to the extent he was diagnosed with tinea cruris and tinea pedis, he had no current symptoms and those conditions had resolved. The threshold matter that must be addressed here (as in any claim seeking service connection) is whether there is competent evidence that the Veteran currently has (during the pendency of the claim has had) the disability for which service connection is sought. The record does not show that the Veteran has (or during the pendency of the instant claim has had) a skin disability. Here, the record does not show any finding, treatment or diagnosis of a skin disability during the pendency of the claim. The mere notations of findings of skin pathology (that might be considered to be etiological factors for a skin disability, if such was currently show, does not meet the threshold requirement (of a current disability) for substantiating a service connection claim. The Veteran does not cite to any current findings that might support that he has had a skin disability during the pendency of the instant claim. Because the evidence does not show that the Veteran has dermatophytosis, tinea cruris and/or tinea pedis he has not presented a valid claim for service connection for a skin disability. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); Brammer v. Derwinski, 3 Vet. App. At 225. Accordingly, the analysis does not need to proceed any further. The appeal in this matter must be denied. As the preponderance of the evidence is against the claim, the governing law and regulations that provide for resolution of reasonable doubt in a claimant’s favor do not apply. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for erectile dysfunction (ED), to include as secondary to service-connected coronary artery disease (CAD), PTSD, and/ or diabetes mellitus type II. The Veteran seeks service connection for erectile dysfunction as secondary to service – connected CAD, PTSD and/ or diabetes mellitus type II. In VA examinations dated July 2011, August 2012 and December 2019, VA clinicians diagnosed the Veteran with erectile dysfunction. See July 2011 Diabetes Mellitus Examination Report, August 2012 and December 2019 Male Reproductive Systems Conditions Disability Benefits Questionnaires. In July 2011, the VA examiner opined that the Veteran’s ED was less likely than not secondary to his diabetes mellitus type II. The rationale for the opinion was that the Veteran’s ED onset was many years prior to his diagnosis of diabetes mellitus. The August 2012 VA examiner opined that while current medical literature provided that the Veteran’s diagnosed service – connected disabilities and the medication used to treat them can cause and / or aggravate erectile dysfunction, it would be speculative to opine to what degree each contributed to the Veteran’s ED. Subsequently, the December 2019 examiner opined that the that the Veteran’s ED was at least as likely as not aggravated by his service – connected CAD, PTSD and diabetes mellitus type II. The rationale was that a review of the medical literature substantiates the claim that CAD, PTSD and diabetes mellitus type II can aggravate erectile dysfunction beyond its natural progression. In light of the foregoing, the Board finds that the evidence is at least in equipoise that the Veteran’s erectile dysfunction is secondary to his service – connected disabilities of CAD, PTSD and diabetes mellitus type II. Resolving all reasonable doubt in the Veteran’s favor as required under the law, entitlement to service connection for erectile dysfunction, as secondary to CAD, PTSD, and diabetes mellitus type II is warranted. Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Increased Rating Claims Disability ratings are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate rating codes identify the various disabilities. Id. The determination of whether an increased rating is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of a matter. VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to a rating in excess of 50 percent prior to December 16, 2019 for service - connected PTSD and in excess of 70 percent thereafter. The Veteran’s service – connected PTSD is rated 50 percent prior to December 16, 2019 and 70 percent thereafter pursuant to 38 C.F.R. § 4.130, DC 9411. Under these criteria, a 50 percent rating is warranted where the psychiatric condition produces occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Global Assessment of Functioning (GAF) scale scores are based on a scale indicating the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Carpenter v. Brown, 8 Vet. App. 240 (1995); Richard v. Brown, 9 Vet. App. 266 (1996); American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders, 4th Ed. (1994) (DSM-IV). The GAF score is based on all of the Veteran’s psychiatric impairments. A GAF score of 51 to 60 represents moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with coworkers). While particular GAF scores are not contained in the VA schedule of ratings for mental disorders, they are a useful tool in assessing a veteran’s disability and assigning ratings. 38 C.F.R. § 4.130. However, they are just one of many factors considered when determining a rating. Evaluation under § 4.130 is symptom-driven, meaning that symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). In Vazquez-Claudio, the United States Court of Appeals for the Federal Circuit explained that the frequency, severity and duration of the symptoms also play an important role in determining the rating. Id. at 117. Significantly, however, the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. 38 C.F.R. § 4.21 (2016); Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the evidence shows that the Veteran suffers symptoms listed in the rating criteria or symptoms of similar severity, frequency, and duration, that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443; see also Vazquez-Claudio, 713 F.3d at 117. The Board notes that there are not any current mental health treatment records to review in the Veteran’s claims file. An August 2012 VA psychiatry mental health consult indicated that the Veteran is being treated for his PTSD and is being managed with Trazadone. The VA psychiatrist noted that the Veteran struggled with PTSD and its chronic vacillating nature. Significantly, the Veteran’s Agent Orange related serious medical conditions were described as a constant trigger for him. The October 2012 VA examiner opined that the Veteran’s service -connected PTSD resulted in occupational and social impairment with occasional decrease in work efficiency. The Veteran arrived at the examination with his girlfriend and indicated that they were relating well. He reported that his son lived with him and his other children lived nearby. The Veteran indicated that they checked on him daily and endorsed a positive relationship. He reported being unable to engage in previously enjoyable activities due to his heart condition. Symptoms of his PTSD included recurrent nightmares, avoidance behaviors, feelings of detachment from others, exaggerated startle response, depression, anxiety, passive suicidal ideation, and chronic sleep impairment. The current global assessment of functioning (GAF) score was 60. Based upon the examiner’s interview with the Veteran, she opined that his trauma related symptoms were subclinical. Notably, the Veteran had maintained employment for thirty years. As noted above the December 2019 VA examiner opined that the Veteran’s PTSD resulted in occupational and social impairment with deficiencies in most areas. The Veteran reported that he had been married twice and divorced. The Veteran lived alone. He was in an ongoing relationship and reported feeling close to his children. Symptoms included nightmares, crying spells, avoidance behaviors, feelings of detachment, exaggerated startle response, chronic sleep problems, depression, anxiety and disturbances of motivation and mood. In light of the foregoing evidence, the Board finds that an increased rating is not warranted. Prior to December 16, 2019, the Veteran’s PTSD symptomatology more closely approximated the criteria for the 50 percent rating. The Veteran’s persistent PTSD symptoms reflected occupational and social impairment with reduced reliability and productivity due to difficulty in understanding complex commands, impairment in memory, disturbance in motivation, chronic sleep impairment, nightmares, flashbacks, hypervigilance, anxiety, depressed mood, difficulty in establishing and maintaining effective work and social relationships, inability establishing and maintaining effective relationships, irritability and anger, and impaired impulse control. The Board acknowledges that the October 2012 VA examiner’s characterization of the Veteran’s occupational and social impairment correlates to a 30 percent rating. While the Board sympathizes with the Veteran and understands that the nature of PTSD results in symptoms that wax and wane, it is nevertheless bound to apply the regulations as written. Here, there is no competent evidence to support a finding that the Veteran’s collective symptoms for the period prior to December 16, 2019, were of the frequency, severity, and duration to have caused occupational and social impairment that approximate the criteria for the next higher 70 percent rating. Mauerhan, 16 Vet. App at 442-43; see also Vazquez-Claudio, 713 F.3d at 116-17. Accordingly, a rating in excess of 50 percent for the period prior to December 16, 2019 is denied. From December 16, 2019, the Veteran’s PTSD appears to have worsened in severity. He related to the December 2019 VA examiner that he had more tearful episodes and increased depressed mood. Such symptoms in combination with the Veteran’s other persistent PTSD symptomatology including panic attacks, difficulty in understanding complex commands, impairment in memory, disturbance in motivation, chronic sleep impairment, nightmares, flashbacks, hypervigilance, anxiety, anger/irritability, and difficulty in establishing and maintaining effective work and social relationships are more adequately contemplated by the criteria for a higher 70 percent rating. However, the Veteran has not demonstrated symptomatology reflective of the criteria for a 100 percent rating. Specifically, he has not been shown to exhibit gross impairment in thought processes or communication; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living; disorientation to time or place; memory loss for names of close relatives, own occupation, or own name; or other symptoms approximating the criteria for a 100 percent schedular rating. Accordingly, from December 16, 2019 a rating in excess of 70 percent is denied. 4. Entitlement to a total disability rating based on individual unemployability due to service - connected disabilities (TDIU). The Veteran contends that he became unable to secure and maintain substantially gainful employment in April 2011 as a result of his service – connected disabilities. Total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340 (a)(1). A total disability rating for compensation purposes may be assigned on the basis of individual unemployability when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16 (a). In such an instance, if there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Id. The Board must evaluate whether there are circumstances in the Veteran’s case, apart from any non-service-connected conditions and advancing age, which would justify a TDIU. 38 C.F.R. §§ 3.341 (a), 4.19; see Van Hoose v. Brown, 4 Vet. App. 361 (1993); see also Hodges v. Brown, 5 Vet. App. 375 (1993); Blackburn v. Brown, 4 Vet. App. 395 (1993). The Veteran’s service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16 (b). The Veteran met the schedular requirements for the assignment of a TDIU for the entirety of the appeal period. See 38 C.F.R. § 4.16 (a). The Veteran is service - connected for PTSD rated at 70 percent, coronary artery disease rated at 60 percent, diabetes mellitus rated at 20 percent, diabetic peripheral neuropathy of the right lower extremity rated at 10 percent, diabetic peripheral neuropathy of the left lower extremity rated at 10 percent, and residuals of cardiac surgical scars associated with coronary artery disease rated at 0 percent. The record shows that the Veteran has a high school education and completed 2 years of college. He was employed as a maintenance mechanic from 1979 until 2011, when he retired. As stated above, the Veteran’s service-connected psychiatric disability has resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. It was also indicated that the Veteran would be limited in his ability to complete tasks in a timely manner, establish healthy interpersonal relationships, partake in a social setting, manage anger, and be consistent, reliable, or productive. In June 2010 hearing testimony, the Veteran endorsed symptoms of difficulty/inability establishing and maintaining effective work/social relationships. He also reported he had problems during his employment with anger dyscontrol and worked the night shift to avoid being around people. VA examinations of the Veteran’s service-connected coronary artery disease indicated that he has additional physical limitations. Symptoms of dyspnea, fatigue, and angina were attributed to his cardiac disability. The Board notes that the Veteran has undergone a quintuple bypass open heart surgery, aortic valve replacement surgery, angioplasty on two separate occasions and suffered a myocardial infarction. The December 2019 VA examiner opined that the Veteran’s condition should not preclude light or sedentary duty because his CAD is stable on medication regimen. However, as noted in this decision the VA examiner did not have the benefit of the Veteran’s most recent aortic valve replacement surgical records when issuing an opinion. VA treatment records reflect that the Veteran requires injectable insulin to control his blood sugar as well as ongoing intermittent chest and leg pain. The Veteran is prescribed nitroglycerin for chest pain. At the December 2019 VA PTSD examination, the Veteran specifically reported that that he could not maintain the persistence and pace required to work after his heart surgery. After weighing all the evidence of record and resolving all doubt in the Veteran’s favor, the Board finds that the Veteran’s service-connected disabilities have rendered him unable to secure and follow a substantially gainful occupation. In particular, the Veteran’s service-connected CAD and diabetic peripheral neuropathy have caused exertional restrictions that limit his ability to perform physically active work. The Veteran’s service-connected PTSD has also caused significant non-exertional restrictions, which further limit his ability to complete tasks in a timely manner, establish work/social relationships, and be consistent, reliable, or productive. Moreover, while the Veteran does have some formal education, his exertional and non-exertional limitations significantly erode his occupational base, making it difficult or nearly impossible for the Veteran to secure and follow a substantially gainful occupation. Therefore, the Board affords the Veteran the benefit of the doubt and find that he has been unable to obtain and maintain any form of substantially gainful employment by reason of his service-connected disabilities. Accordingly, the criteria for TDIU have been met. 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS FOR REMAND 1. Entitlement to service connection for hypertension to include as secondary to herbicide exposure and/or service - connected PTSD is remanded. Unfortunately, there has not been substantial compliance with the Board’s previous remand directives. The April 2019 remand directed that the Veteran be examined to determine the nature and etiology of his hypertension as directly related to service, including Agent Orange exposure. The remand directive specifically referenced the National Academy of Science (NAS) Update 11 dated November 2018 which elevated hypertension from its previous classification in the “Limited or Suggestive Evidence” category to the “Sufficient Evidence” category for association with herbicide agents and asked that the examiner consider this data on a direct basis. The rationale for the examiner’s negative nexus opinion was the fact that hypertension is not a presumptive condition. However, the opinion did not consider the scientific findings by NAS on a direct basis. Accordingly, remand for an addendum medical opinion is warranted. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 2. Entitlement to a rating in excess of 60 percent for coronary artery disease (CAD) status post myocardial infarction w/coronary artery bypass grafting times 5. During the appeals period, the Veteran had an aortic valve replacement with a private healthcare provider. See e.g., September 2018 Addendum, Jacksonville VA Outpatient Clinic (OPC) and December 2019 VA Heart Examination. However, those records are not associated with the Veteran’s claims file. Nor does the December 2019 VA examination report indicate whether the aortic valve replacement represents a worsening of the Veteran’s service – connected coronary artery disease. Pursuant to the diagnostic code, the Veteran may be entitled to a higher rating as a result of the aortic valve replacement, however further development is required before the claim can be fairly and properly adjudicated. Accordingly, remand to obtain relevant medical treatment records and an addendum medical opinion is warranted. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The matters are REMANDED for the following action: 1. Obtain any outstanding, pertinent VA treatment records and private records and associate the records with the claims file. Any negative reply should be properly included in the claims file. 2. Forward the Veteran’s claims folder to an appropriate VA examiner for an addendum opinion as to the etiology of the Veteran’s hypertension. The examiner should review the Veteran’s claims file (to include this remand) and provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s hypertension is related to his active duty service, and specifically to his exposure to herbicide agents therein. In rendering the above opinion, the examiner must specifically consider and discuss the NAS Veterans and Agent Orange: Update 11 dated November 2018 that discusses the association between hypertension and herbicide exposure. The examiner is advised that the Board is cognizant that there is no VA presumption of service connection for hypertension as due to herbicide agent exposure. However, the Agent Orange Updates speak to associations between exposure to chemicals and health outcomes in human populations, and not to the likelihood that any individual’s health problem is associated with or caused by the herbicide agents in question. Thus, the question here is what is the likelihood that this Veteran’s hypertension is related to his herbicide agent exposure? If the examiner is unable to provide the requested opinion without resorting to speculation, the examiner should so specify, along with an explanation as to why that is so. If the examiner determines that the requested opinion may not be rendered without an examination of the Veteran, such should be scheduled. 3. Schedule the Veteran for an examination to determine the current level of disability regarding his heart disability. A history should be taken from the Veteran. The examiner should provide consideration of and description of any procedures performed on the Veteran’s heart, to specifically include the aortic valve replacement suggested by the record. Jennifer White Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Alexander 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.