Citation Nr: 21010130 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 17-66 449 DATE: February 24, 2021 REMANDED Entitlement to service connection for hypertension secondary to posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1968 to April 1972. In January 2021, the Veteran testified before the undersigned at a virtual Board hearing. The transcript from the hearing has not yet been associated with the file, as the case is being remanded under the Board’s “One Touch” program. The hearing transcript will still be processed and associated with the claims file in the ordinary course of business. It is clear that VA records are outstanding. The most recent records in the file are dated in 2017, yet the Veteran testified that he continues to receive VA medical care for his hypertension. These records must be obtained. The Veteran seeks service connection for hypertension, secondary to service-connected PTSD. He has submitted medical articles suggestive of a positive correlation between hypertension and PTSD (see January 2016 and February 2017 correspondences). While a VA medical nexus opinion was obtained in March 2016, the examiner at the time focused on blood pressure during the acute phase of the disease, and explained that there is no medical literature substantiating a claim that PTSD permanently elevates blood pressure. However, in doing so, the examiner used the wrong standard. The Court has held that aggravation in the secondary service connection context does not require permanent worsening. See Ward v. Wilkie, 31 Vet. App. 233 (2019) (holding that secondary service connection is warranted for any incremental increase in disability, meaning any additional impairment of earning capacity above the degree of disability existing before the increase, in a nonservice-connected disability resulting from a service-connected disability, regardless of its permanence). Thus, the Board finds that a remand is required for obtaining a medical addendum opinion. Moreover, although the Veteran had initially filed for service connection for hypertension secondary to PTSD, as the Veteran’s service records show that he served in the Republic of Vietnam, his in-service herbicide exposure is presumed. To date, hypertension is not an enumerated disability entitled to presumptive service connection based on exposure to herbicide agents under 38 C.F.R. § 3.309(e). However, under Combee, service connection may still be awarded based on that exposure on a direct basis. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). In the 2018 update to the National Academy of Sciences’ (NAS) report, “Veterans and Agent Orange,” hypertension was upgraded from its previous classification in the category of “limited or suggestive” evidence of an association to herbicide agents, to the category of “sufficient” evidence of an association to herbicide agents. According to the NAS, “[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide agent exposure. The Board declines to take judicial notice of the findings and conclusions found in the 2018 update to the NAS report, as this literature does not include facts of universal notoriety that are not subject to reasonable dispute. Monzingo v. Shinseki, 22 Vet. App. 97, 103 (2012). However, the Board will take judicial notice that the 2018 update to the NAS report “Veteran and Agent Orange” exists and finds than an addendum medical opinion is warranted for a VA examiner to consider this report in relationship to the Veteran’s medical history. The matter is REMANDED for the following actions: 1. Obtain and associate with the Veteran’s claims file VA outpatient treatment records from Houston VA medical center, to include from Texas City CBOC, from October 2017 to the present. 2. Return the Veteran’s claims file to the March 2016 VA examiner or to another examiner if that person is no longer available for an addendum medical opinion. The examiner should answer the following questions: (a.) Is it at least as likely as not the Veteran’s current hypertension condition is related to in-service disease or injury, to include his exposure to Agent Orange? Please expressly consider the 2018 NAS Update (finding sufficient evidence of an association of hypertension with the chemicals of interest based on new evidence and a review of prior studies). The examiner must provide a complete rationale for any opinion. However, the examiner is advised that simply stating the condition is not on the list of diseases presumptively associated with Agent Orange exposure is not sufficient rationale for a negative opinion. (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s hypertension was caused or aggravated by his service-connected PTSD? In doing so, the examiner should also consider and address the medical articles submitted by the Veteran (see January 2016 and February 2017 correspondences). In doing so, the examiner should understand that “aggravation” means any incremental increase in disability, meaning any additional impairment of earning capacity above the degree of disability existing before the increase, regardless of its permanence. A rationale for all requested opinion shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall explain whether additional information is needed or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Lee 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.