Citation Nr: 21013020 Decision Date: 03/08/21 Archive Date: 03/08/21 DOCKET NO. 18-14 821 DATE: March 8, 2021 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for chronic kidney disease is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1964 to March 1966. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Janesville, Wisconsin. The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in October 2019; a transcript is of record. The Board previously remanded this matter in December 2019 and September 2020 for further development. As discussed below, unfortunately another remand is necessary. 1. Entitlement to service connection for hypertension is remanded. 2. Entitlement to service connection for chronic kidney disease is remanded. Unfortunately, another remand is necessary as there has not been substantial compliance with the directives of the September 2020 Board remand. See Stegall v. West, 11 Vet. App. 268 (1998) (a remand confers upon the claimant, as a matter of law, the right to compliance with the remand directives); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (noting that Stegall requires substantial compliance with remand orders, rather than absolute compliance). The September 2020 Board remand instructed the RO to obtain VA medical opinions for the Veteran’s claimed conditions of service connection for hypertension and chronic kidney disease. Although the Board acknowledges receipt of the November 2020 medical opinions, these opinions are inadequate. In regard to the Veteran’s hypertension, the November 2020 VA examiner did not opine on whether the Veteran’s hypertension was related to his in-service herbicide exposure, or discuss the recent publication, Veterans and Agent Orange Update 11 (2018) by the National Academies of Sciences, Engineering, and Medicine, despite being instructed to do so in the September 2020 Board remand. Furthermore, the September 2020 Board remand instructed the VA examiner to discuss whether the Veteran’s medications that he takes for his service-connected psoriasis and hepatitis either cause or aggravate his hypertension. The November 2020 VA examiner stated that the Veteran does not take medication for his hepatitis, and offered a vague statement that “there is no plausible mechanism for htn to be aggravated by his sc dx or meds for such…to control psoriasis and hepatitis meds and diagnoses proceed independently from the NSC htn.” The Board finds that the VA examiner's opinion that the Veteran’s hypertension is not caused or aggravated by the medications he takes for his service-connected psoriasis or hypertension because they “proceed independently” to be unclear. In regard to the Veteran’s chronic kidney disease, the November 2020 VA examiner did not address the Veteran’s assertion that the medication used to treat his psoriasis causes sudden “kidney flare-ups” and kidney problems, despite being instructed to do so in the September 2020 Board remand. The September 2020 Board remand also instructed the VA examiner to explain whether any acute elevations in creatinine levels due to the Veteran’s psoriasis medication cause any increase in the severity of his kidney disease, regardless of its permanence. The November 2020 VA examiner stated that it is a rare etiology for chronic kidney disease due to a diagnosis or medication for psoriasis; the examiner also stated that “meds for SC psoriasis caused hepatitis-and?renal acutely ONLY and reversed any acute renal change in 2003”. The Board finds this statement unclear. Furthermore, if the VA examiner used the term “reverse” to mean that the psoriasis medication’s impact on the Veteran’s creatine levels was only temporary, the Board reminds the examiner that a permanent worsening is not required to establish aggravation. On remand, a clear and complete rationale should be given for the VA examiner’s opinion. Therefore, remand is necessary in order to comply with the September 2020 Board Remand instructions. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician, preferably a different clinician than the clinician that provided the November 2020 opinion(s), to determine the nature and etiology of the Veteran’s hypertension and chronic kidney disease. The entire claims file, to include a copy of this remand, should be reviewed by the examiner and its review should be noted in the examination report. Hypertension (a) The examiner is asked to opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's hypertension is the result of his in-service exposure to herbicide agents. * In formulating his or her opinion, the examiner should consider and address the recent National Academies of Sciences, Engineering, and Medicine publication Veterans and Agent Orange Update 11 (2018) finding "sufficient evidence of an association" between hypertension and herbicide agents such as Agent Orange. (b) The examiner is asked to opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's hypertension was either (i) caused by or (ii) aggravated by the medications taken to treat his service-connected psoriasis. (c) The examiner is asked to opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's hypertension was either (i) caused or (ii) aggravated by any medications taken to treat his service-connected hepatitis. * The examiner is advised that a permanent worsening of is not required to establish aggravation; rather, aggravation may include temporary worsening, or flare-ups, of a disability. Chronic kidney disease (a) The examiner is asked to opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's kidney disease is the result of his in-service exposure to herbicide agents. (b) The examiner is asked to opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's kidney disease was either (i) caused by or (ii) aggravated by the medications taken to treat his service-connected psoriasis. * Concerning aggravation, the examiner should address the Veteran's assertion that the medication used to treat his psoriasis causes sudden "kidney flare-ups" and kidney problems. * The examiner should explain whether any acute elevations in creatinine levels due to the Veteran's psoriasis medication cause any increase in the severity of his kidney disease, regardless of its permanence. (c) The examiner is asked to opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's kidney disease was either (i) caused or (ii) aggravated by any medications taken to treat his service-connected hepatitis. * The examiner is advised that a permanent worsening of is not required to establish aggravation; rather, aggravation may include temporary worsening, or flare-ups, of a disability. The examiner must provide a comprehensive report that includes a complete rationale for all opinions and conclusions reached. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Mohammad 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.