Citation Nr: 21013908 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 16-05 782 DATE: March 10, 2021 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a neurological disorder in the bilateral upper extremities, claimed as numbness in the fingertips, is remanded. REASONS FOR REMAND The Veteran had active duty from October 1966 through October 1968, to include service in Vietnam. The issues on appeal arise from the Veteran’s April 2013 claim and the agency of original jurisdiction’s (AOJ’s) February 2014 rating decision which denied the issues on appeal. This matter was remanded previously by the Board in September 2018. The AOJ has undertaken efforts to complete the development directed by the Board and the matter now returns for the Board’s review. Although the Board regrets the further delay, additional development is necessary. 1. Medical opinion as to whether the Veteran’s hypertension was caused by in-service herbicide exposure. The Veteran is presumed as having been exposed to herbicides based on his service in Vietnam. In conjunction with the same, he asserts credibly that he received an initial hypertension diagnosis in 1997 or 1998. Post-service private treatment records show that the Veteran has indeed remained under treatment for hypertension. The regulations do not currently identify hypertension as being among those diseases that may be presumed as having resulted from in-service herbicide exposure. 38 C.F.R. § 3.309(e). Nonetheless, the National Academy of Sciences (NAS) issued an update on Veterans and Agent Orange that moved hypertension from the "limited or suggestive evidence" category to the "sufficient evidence of an association" category. See Nat'l Acad. of Sci., Inst. of Med., Veterans and Agent Orange: Update 11 (2018), available at https://www.nap.edu/resource/25137/111318_VAO_2018_highlights.pdf (accessed on January 25, 2021). Given the 2018 NAS update, there is an indication that the Veteran's diagnosed hypertension may be associated with his herbicide exposure during service, thus triggering VA's duty to obtain a medical opinion as to that question. See McLendon v. Nicholson, 20 Vet. App. 79, 84 (2006). Although the Veteran was afforded a hypertension examination in March 2019, no opinion as to whether the Veteran’s hypertension resulted from his in-service herbicide exposure was solicited or received. Accordingly, VA must now obtain a medical opinion as to whether the Veteran’s hypertension was caused by or resulted from in-service herbicide exposure. 2. Medical opinion as to whether the neuropathies in the Veteran’s upper extremities are related etiologically to his active duty service, to include herbicide exposure, and/or service-connected diabetes. The post-service treatment records document complaints by the Veteran of decreased sensation in his hands beginning in 2007. The records are notable for various comorbidities that are plausible pathologies for the Veteran’s neurological symptoms, including: cervical radiculopathy (shown in an August 2007 nerve conduction study); bilateral carpal tunnel syndrome (also diagnosed in 2007); and, diabetes (diagnosed in 2019). Service connection is in effect for diabetes. It remains unclear from the record as to whether the neurological abnormalities (diagnosed as neuropathies) in the Veteran’s upper extremities were caused by his active duty, to include in-service herbicide exposure, or by his service-connected diabetes, or by his non-service-connected cervical radiculopathy and/or carpal tunnel syndrome. During a March 2019 examination, the examiner appeared to suggest that the Veteran had peripheral neuropathies that were caused by his diabetes. The examiner gave no explanation for that opinion, and moreover, it is unclear from the opinion as to whether that opinion is limited only to the Veteran’s lower extremities or whether the opinion included conditions in the Veteran’s upper extremities. This uncertainty is exacerbated by a June 2020 examination, which appears to conclude that axonal sensory neuropathies in the Veteran’s upper extremities were likely attributable to the Veteran’s carpal tunnel syndrome. The Board observes also that even if the evidence showed clearly that the neuropathies in the Veteran’s upper extremities were caused by the Veteran’s carpal tunnel syndrome, the June 2020 examiner does not rule out the possibility that the neuropathies might have been aggravated by his service-connected diabetes and provides no opinion in that regard. Under the circumstances, VA should obtain a medical opinion as to whether the neurological disorders in the Veteran’s upper extremities were caused by an in-service injury, illness, or event, to include in-service herbicide exposure, or alternatively, were caused or aggravated by his service-connected diabetes. The matters are REMANDED for the following action: 1. The Veteran should be asked whether he has additional evidence pertaining to his claims on appeal. Records for VA treatment received by the Veteran and any relevant private treatment identified by the Veteran and not already of record should be obtained. If the records are not available, such unavailability should be documented in the record. The Veteran and his representative should be notified of unsuccessful efforts in order to allow them the opportunity to obtain and submit those records for VA review. 2. After the development ordered in Paragraph 1 is completed, obtain a medical opinion as to whether it is at least as likely as not (at least a 50 percent probability) that the Veteran’s hypertension was caused by or resulted from his presumed herbicide exposure during service. The claims file should be made available to the reviewing clinician and the reviewing clinician should review the claims file in forming the requested opinion. The reviewing clinician should provide a detailed rationale that explains fully all of the reasons for the given opinions. If the reviewing clinician determines that a full examination of the Veteran is necessary in order to render the requested opinion, then such an examination should be afforded to the Veteran. 3. After the development ordered in Paragraph 1 is completed, obtain medical opinions as to whether it is at least as likely as not (at least a 50 percent probability) that: 1) the neuropathies in the Veteran’s upper extremities were caused by or resulted from an injury, illness, or event that occurred during active duty service, to include presumed herbicide exposure; 2) the neuropathies in the Veteran’s upper extremities were caused by or resulted from the Veteran’s service-connected diabetes; and/or 3) the neuropathies in the Veteran’s upper extremities are aggravated by the Veteran’s service-connected diabetes. The claims file should be made available to the reviewing clinician and the reviewing clinician should review the claims file in forming the requested opinion. The reviewing clinician should provide a detailed rationale that explains fully all of the reasons for the given opinions. If the reviewing clinician determines that a full examination of the Veteran is necessary in order to render the requested opinions, then such an examination should be afforded to the Veteran. 4. After completion of the above development, the issues on appeal should be readjudicated. If the determination remains adverse to the Veteran, he and his representative should be furnished with a SSOC and be given an opportunity to respond. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D.S. 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.