Citation Nr: 21012499 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 14-34 592A DATE: March 4, 2021 REMANDED Entitlement to service connection for hypertension, as secondary to diabetes mellitus type 2 is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from January 1965 to October 1967. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a February 2012 rating decision issued by a VA Regional Office (RO). By way of background, this matter was previously before the Board in November 2018 in which the claims for entitlement to service connection for hypertension, as secondary to diabetes mellitus type 2 (diabetes) as well as peripheral neuropathy of the lower extremities were remanded. Subsequent, to further development by the RO, the claims for bilateral peripheral neuropathy of the lower extremities was granted in a May 2020 rating decision. As such, these claims are no longer before the Board for adjudication. As part of the November 2018 remand, the Veteran was to be afforded a new VA examination to provide an adequate medical opinion that addressed both causation as well as aggravation for his currently diagnosed hypertension. As will be discussed below, the resulting opinion was not responsive to the Board's directive and, therefore, further remand is required. See Stegall v. West, 11 Vet. App. 268, 271(1998). Entitlement to service connection for hypertension, as secondary to diabetes mellitus type 2 is remanded. The Veteran asserts that his hypertension is caused or aggravated by his service-connected diabetes mellitus type 2 (diabetes). To that affect, the Veteran was afforded a new VA examination in October 2019. The examiner opined that the Veteran’s hypertension was less likely than not proximately due to or the result of the Veteran’s diabetes. He explained that the Veteran’s hypertension was “diagnosed a long period of time prior to diagnosis of Type II [diabetes mellitus]”. The examiner further noted that the Veteran’s “diabetic control has not been optimum” and concluded that there was “no clinical evidence of a cause and effect relationship at this time”. The Board finds the October 2019 VA examination to be inadequate for adjudicative purposes. For one, the VA examiner found a causative link between hypertension and diabetes unlikely because hypertension was diagnosed before diabetes. As the Court explained in Frost v. Shulkin, however, there is no temporal requirement inherent in 38 C.F.R. § 3.310(a) even when the Veteran claims that the primary condition caused the secondary condition. 29 Vet. App. 131 (2017). Thus, it is not necessary for the primary condition to be service connected, or even diagnosed, at the time the secondary condition is incurred. It is quite possible, for example, that the Veteran’s diabetes existed long before it was diagnosed and thus could still have caused hypertension. Since the VA examiner’s opinion was primarily based on the timing of the Veteran’s diabetes diagnosis versus the hypertension diagnosis, the Board finds the rationale inadequate to render a decision at this time. Secondly, the Board’s November 2018 remand directives specifically requested that the VA examiner opine as to both causation and aggravation. The October 2019 examiner focused solely on causation and neglected to provide an opinion regarding whether the diabetes mellitus type 2 has aggravated the hypertension. A medical opinion that addresses only causation and not aggravation is inadequate to adjudicate a claim for service connection on a secondary theory of entitlement based on aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). As such, a remand is required to obtain a medical opinion that adequately addresses both causation and aggravation for the Veteran’s hypertension as outlined above. The Board further notes, that the Veteran has recently asserted a new theory of entitlement to service connection for his current hypertension. The Veteran, through his representative, now asserts in the alternative that his hypertension is directly caused by exposure to herbicide agents. See Informal Hearing Presentation dated February 26, 2021. To support that theory of entitlement, the Veteran’s representative referenced two medical articles, “Veterans and Agent Orange (AO): Update 11” (2018) and the 2018 updated publication “Veterans and Agent Orange” by the National Academy of Science (NAS). Both, it was contended, indicate that there is now sufficient evidence of an association between hypertension and herbicide agent exposure to warrant service connection. The Board notes, that the Veteran’s exposure to herbicide agents has been already conceded and indeed linked to his diabetes, which he is now service connected. In light of the medical literature referenced by the Veteran’s representative showing suggestive evidence of an association between hypertension and Agent Orange exposure, the Board finds the addendum medical opinion must also address this alternative theory of entitlement to service connection. See 38 U.S.C. § 5103A; McClendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion from an appropriate clinician regarding the Veteran’s claim seeking service connection for hypertension. The examiner is directed to review the claims folder. Whether a physical examination is necessary is left to the discretion of the examiner. After a thorough review of the claims file and examination (to the extent necessary), the examiner is asked to address the following: (a) whether the Veteran’s hypertension was at least as likely as not (50 percent probability) (i) incurred in service, (ii) incurred within a year of service, or (iii) caused by service, to include the Veteran’s conceded exposure to Agent Orange herbicides. The examiner is cautioned that an opinion based solely on the fact that any diagnosed condition is not a presumptive condition for herbicide exposure is not sufficient. Rather, the examiner is to address the Veteran’s specific military history, exposure history, medical history, risk factors, and any other relevant factors in ascertaining whether his hypertension is attributable to service in light of his in-service herbicide exposure. The examiner should consider the medical articles referenced by the Veteran indicating a relationship between herbicide exposure and hypertension: “Veterans and Agent Orange (AO): Update 11” (2018) and the 2018 updated publication “Veterans and Agent Orange” by the National Academy of Science. (b) If the Veteran’s hypertension is not found to be directly caused by in-service herbicide exposure, the examiner then must opine whether the Veteran’s hypertension is at least as likely as not (a 50 percent or greater probability) proximately due to or aggravated beyond its natural progression by the Veteran’s service-connected diabetes mellitus type II. The examiner is cautioned that there is no temporal requirement inherent in 38 C.F.R. § 3.310, even when the Veteran claims that the primary condition (diabetes) caused the secondary condition (hypertension). Therefor, for a veteran to be service connected on a secondary basis under a causation theory, the primary disability (diabetes) need not be service connected, or even diagnosed, at the time the secondary condition is incurred. In other words, the examiner may not discount the possibility of causation merely because hypertension was diagnosed before diabetes. With regard to the term "aggravated," as used in 38 C.F.R. § 3.310 (b), the examiner is cautioned that this term does not require that there be "permanent worsening" of the nonservice-connected disability. Instead, secondary service connection is warranted for "any incremental increase in disability and any additional impairment of earning capacity in nonservice-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase regardless of its permanence." See Ward v. Wilkie, 31 Vet. App. 233, 239 (2019). (Continued on the next page)   The examiner should review the entire claims file, including any relevant lay statements and medical evidence. 2. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal. Shereen M. Marcus Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. F. Minnitte, Attorney Advisor 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.