Citation Nr: 21011658 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 09-40 792 DATE: March 2, 2021 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for cerebrovascular accident (CVA) is remanded. Entitlement to a total disability rating based on individual unemployability as a result of service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran had active service from August 1969 to July 1971, to include service in the Republic of Vietnam. The Board denied the Veteran’s claims in August 2014, and the Veteran appealed to the United States Court of Appeals for Veterans Claims (“CAVC” or “the Court”). In May 2015, the Court issued an order that vacated the Board decision and remanded the claims for compliance with a Joint Motion for Remand (JMR). The Board remanded the claims for further development in September 2015 and June 2019. Unfortunately, this case must be remanded again for compliance with the Board’s prior June 2019 remand. See Stegall v. West, 11 Vet. App. 268 (1998). In its June 2019 remand, the Board recognized that the Veteran was presumptively exposed to herbicide agents due to his service in the Republic of Vietnam. In addition, the Board noted that the National Academy of Science (NAS) Institute of Medicine’s Veterans and Agent Orange: Update 11 (2018) upgraded hypertension from its previous classification in the category of “limited or suggestive” evidence of an association with exposure to Agent Orange, 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 agent exposure. Consequently, the Board instructed the VA examiner to consider the NAS discussion of hypertension as an effect of Agent Orange exposure in Veterans and Agent Orange: Update 11 (2018), Washington, DC: The National Academies Press at pp. 487-498. Unfortunately, the January 2020 VA examiner did not address the NAS discussion in his opinion. In addition, the Veteran recently submitted into the record a number of articles on the relationship between PTSD and hypertension on February 19, 2020. The examiner should also consider these medical articles in the opinion. Regarding the Veteran’s service connection claim for a CVA and the claim for a TDIU, these claims are inextricably intertwined with the adjudication of the other remanded issue, thus these claims must also be remanded. The matters are REMANDED for the following action: 1. Obtain all outstanding VA and private clinical records regarding treatment for the Veteran’s hypertension, CVA, and PTSD. 2. Then, obtain a medical opinion to address the etiology of the Veteran’s hypertension. If an examination is needed to address the Board’s questions, one should be scheduled. The examiner should offer the following opinions: a. Is it at least as likely as not (50 percent probability or greater) that the Veteran’s hypertension is causally or etiologically related to the Veteran’s active service, to include his presumed herbicide agent exposure? The examiner should specifically consider the National Academy of Sciences, Engineering, and Medicine’s (NAS) discussion of hypertension as an effect of Agent Orange exposure in Veterans and Agent Orange: Update 11 (2018), Washington, DC: The National Academies Press at pp. 487-498. b. Is it at least as likely as not (50 percent or greater probability) that any hypertension was caused by the Veteran’s service-connected PTSD? Why or why not? c. Is it at least as likely as not (50 percent or greater probability) that any hypertension was aggravated (i.e. made worse) by the Veteran’s service-connected PTSD? Why or why not? The examiner should also consider the other medical articles regarding PTSD and hypertension the Veteran submitted on February 19, 2020. If aggravation is found, the examiner should attempt to establish the baseline level of severity of the nonservice-connected disease or injury by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 3. Readjudicate the issues of entitlement to service connection for hypertension and CVA, and entitlement to a TDIU. Roya Bahrami Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Berryman, 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.