Citation Nr: 21010550 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 18-09 350 DATE: February 25, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to coronary artery disease (CAD), is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from October 1964 to August 1966, to include service in Vietnam. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an April 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office in Chicago, Illinois. This case was previously before the Board in June 2018 and October 2019, when it was remanded to the agency of original jurisdiction (AOJ) for additional development. On both occasions, after taking further action, the AOJ confirmed and continued the prior denial and returned the case to the Board. Entitlement to service connection for hypertension, to include as secondary to CAD, is remanded. Although further delay is regrettable, the Board finds that additional development is necessary prior to appellate review. A remand by the Board confers on the Veteran the right to compliance with the remand. Stegall v. West, 11 Vet. App. 2689 (1998). In the October 2019 remand, the Board requested a medical opinion as to whether the Veteran’s hypertension had been caused or aggravated by his service-connected CAD. The Board also requested an opinion as to whether his hypertension was related to his period of service, including his presumed in-service exposure to herbicide agents in Vietnam. The Board asked that the examiner consider and discuss an article the Veteran’s representative cited in an April 2018 Informal Hearing Presentation (IHP) with respect to the “strong and consistent link between hypertension and coronary artery disease.” See “Hypertension and coronary artery disease: cause and effect” at https://www.ncbi.nlm.nih.gov/ pubmed/8576788. The Board also asked that the examiner consider information from the National Academy of Sciences to the effect that there is sufficient evidence of an association between hypertension and exposure to herbicides. In a November 2019 VA medical opinion, an examiner quoted from the aforementioned article “Hypertension and coronary artery disease: cause and effect,” that “[e]pidemiological data indicate a strong and consistent link between hypertension and coronary artery disease. This does not mean that hypertension is the cause of coronary artery disease . . .” After quoting that excerpt, the examiner stated that “[c]oronary [h]eart [d]isease does NOT cause hypertension.” The Board finds that the examiner’s opinion is inadequate. First, the examiner did not explain the rationale for her conclusion that CAD does not cause hypertension. As noted, the article states that there is a strong link between the two. Critically, the cited excerpt indicates that hypertension is not necessarily the cause of CAD; it does not state that CAD is not the cause of hypertension, as the examiner concluded. Moreover, as to the information from the National Academy of Sciences, the examiner stated only that hypertension was not a presumptive Agent Orange condition and that “there is no conclusive evidence of [a] direct relationship between exposure and hypertension.” In so doing, however, the examiner appears to have applied a standard of proof beyond the “at least as likely as not” standard the Board set out in the remand. In addition, the fact that a presumption of service connection is not available for a particular disability does not preclude an award of service connection on a facts-found basis. Under the circumstances, a new opinion is required. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). This matter is REMANDED for the following action: 1. Obtain copies of records pertaining to any VA treatment the Veteran has received since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record. 2. After the foregoing development has been completed, obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran’s hypertension. After reviewing the record, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that hypertension had its onset in, or is otherwise attributable to, the Veteran's period of active service, to include as a result of his presumed in-service exposure to herbicide agents in Vietnam. In so doing, the examiner should consider information from the National Academy of Sciences to the effect that there is sufficient evidence of an association between hypertension and exposure to herbicides. See National Academy of Sciences Report: Veterans and Agent Orange: Update 11 (2018). If it is the examiner’s opinion that it is unlikely that the Veteran’s hypertension had its onset in, or is otherwise attributable to, the Veteran's period of active service, to include as a result of his presumed in-service exposure to herbicide agents in Vietnam, the examiner should offer a further opinion as to whether it is at least as likely as not that such disability has been (a) caused or (b) aggravated (worsened beyond natural progression) by the Veteran’s service-connected coronary artery disease. In so doing, the examiner should discuss the article referenced in the Veteran’s April 2018 IHP (“Hypertension and coronary artery disease: cause and effect” published at https://www.ncbi.nlm.nih.gov/ pubmed/8576788). A complete medical rationale for all opinions expressed must be provided. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issue on appeal should be readjudicated based on the entirety of the evidence. If the benefit sought remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Kettler, 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.