Citation Nr: 21014677 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 15-45 179 DATE: March 15, 2021 REMANDED Entitlement to service connection for hypertension, claimed as due to herbicide agent exposure, or as secondary to service connected acquired psychiatric disorder, to include bipolar disorder and depression, is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from September 1966 to April 1969, with subsequent service in the U.S. Army Reserve. This matter comes before the Board of Veterans’ Appeals (Board) from a September 2013 rating decision of a Department of Veteran’s Affairs (VA) Regional Office (RO), which, in pertinent part, denied service connection for hypertension. In November 2013, VA received the Veteran’s Notice of Disagreement. Following the issuance of a Statement of the Case (SOC) in October 2015, the Veteran perfected a timely appeal via his submission of a VA Form 9 in December 2015. The Veteran indicated he did not want a hearing. In September 2018 and July 2020, the Board remanded the matter for further evidentiary development. 1. Hypertension The Veteran contends that his currently diagnosed hypertension was caused by in-service herbicide agent exposure. Specifically, he contends his unit was stationed at Camp Knox in Korea and while he was washing vehicles and equipment, he was exposed to Agent Orange. Additionally, the Veteran also contends his current service connected acquired psychiatric disorder, to include bipolar disorder and depression, are causing or aggravating his hypertension. See e.g. July 2010 Statement in Support of Claim and September 2018 IHP. The Board acknowledges that the Veteran’s service personnel records confirm that the Veteran was stationed in Korea approximately from April 1968 to April 1969, as part of the 6th/ 80th Artillery, the Veteran was stationed at Ft. Knox, Korea, which was located near the Korean Demilitarized Zone (DMZ). Pursuant to the Board’s July 2020 remand instructions, a VA medical opinion was obtained in October 2020. After reviewing the record, and the November 2016 Journal of Occupation and Environmental Medicine, the VA examiner opined the hypertension is less likely than not related to Agent Orange exposure. The VA examiner explained, first, hypertension is not included in the VA list of presumptive conditions secondary to agent orange exposure. Secondly, while one article presented an association of occupational herbicide exposure and hypertension, it is a known fact that “association does not equal causation.” During this examination, the VA examiner addressed the November 2016 Journal of Occupational and environmental medicine, but fails to address the National Academy of Sciences (NAS) study, which the Veteran’s representative references in the September 2018 IHP. As to the October 2020 VA examiner failed to consider this study in rendering the negative opinion, an addendum opinion is required. As to the Veteran’s theory of entitlement to service connection on a secondary basis, pursuant to the Board’s July 2020 remand instructions, a VA medical opinion was obtained in July 2020. After reviewing the record, the VA examiner opined the Veteran’s hypertension is less likely than not caused by or related to psychiatric disorder. The VA examiner explained although blood pressure readings may be transiently elevated due to numerous reasons, including psychiatric disorder, stress, anxiety, pain, medications, alcohol, or improper reading technique, none of these cause the permanent non-transient elevation of blood pressure diagnostic for hypertension. The VA examiner also opined that Veteran’s hypertension was not incrementally increased or aggravated beyond natural progression by the service-connected psychiatric disability. The VA examiner noted there was no documentation of aggravation and blood pressure remained normal during psychotic attacks. The Board finds the opinion provided by the VA examiner was inadequate as the incorrect legal standard was used by the examiner. Specifically, a permanent worsening of a nonservice-connected disability is not required to establish secondary service connection on the basis of aggravation. Ward v. Wilkie, 31 Vet. App. 233 (2019). Thus, an addendum opinion is required. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The matters are REMANDED for the following action: 1. Obtain an addendum opinion from the previous VA examiner, or other appropriate VA clinician in order to obtain a medical opinion as to the etiology of the Veteran’s diagnosed hypertension. The reviewing physician is advised that “Veterans and Agent Orange: Update 11,” published by NAS in 2018 reclassified the possible association between hypertension and exposure to agent orange from “limited or suggestive” to “sufficient.” The need for examination of the Veteran is left to the discretion of the clinician rendering the requested opinion. Following a review of the claims file and consideration of the updated NAS finding of “sufficient” evidence of a positive association between hypertension and exposure to herbicides in Korea near the DMZ, the examiner should provide the following: (a.) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s hypertension is due to exposure to herbicides on a direct incurrence basis. A rationale must be included for all opinions expressed. (b.) If not, is it at least as likely as that hypertension was proximately due to or the result of service-connected acquired psychiatric disorder, to include bipolar disorder and depression? (c.) Is it at least as likely as not that hypertension was aggravated (made worse) by service-connected acquired psychiatric disorder, to include bipolar disorder and depression? If aggravation is found, the examiner must attempt to establish a baseline level of severity prior to aggravation. In providing the requested opinions, the clinician should consider the Veteran’s reported symptoms in service and thereafter, including the nature, onset, progression and severity of the Veteran’s reported symptoms. If there is any medical reason to accept or reject the proposition that exposure to herbicide agents caused the development of hypertension, or that hypertension was caused or aggravated by acquired psychiatric disorder, to include bipolar disorder and depression, this should be noted. Stated another way, do the Veteran’s reports about his symptoms align with how hypertension is known to develop or are the Veteran’s reports generally inconsistent with medical knowledge or implausible? It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” (38 C.F.R. § 4.1), copies of all pertinent records in the Veteran’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 2. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL. IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE CORRECTIVE ACTION MUST BE IMPLEMENTED. IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION. (Continued on the next page) T. Berry Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Penn, 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.