Citation Nr: 21014933 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 16-04 192 DATE: March 16, 2021 REMANDED 1. Entitlement to service connection for hypertension is remanded. 2. Entitlement to service connection for multiple lipomas on whole body is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from July 1968 to December 1969. These matters are before the Board of Veterans’ Appeals (Board) on appeal of an August 2012 Department of Veterans Affairs (VA) rating decision. In May 2018, these matters and matters of entitlement to service connection for diabetes mellitus and a heart condition were remanded for additional development following the lifting of a stay regarding claims involving allegations of exposure to herbicide agents in the coastal waters of Vietnam. [A June 2020 rating decision awarded service connection for coronary artery disease, rated 30 percent effective January 3, 2012 and for type 2 diabetes mellitus, rated 20 percent, effective December 12, 2002, resolving the appeals in those matters.] 1. Service connection for hypertension. The May 2018 Board remand ordered an examination to determine the etiology of the Veteran’s hypertension if he was found to have been exposed to herbicide agents in service. The examiner was to specifically address the November 2018 National Academy of Sciences (NAS) report, which upgraded the relationship between hypertension and herbicide exposure from “limited or suggestive” to “sufficient,” indicating that “there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. A June 2020 VA memorandum conceded the Veteran was exposed to herbicide agents is service based on his service in service in the offshore waters of Vietnam. In an October 2020 VA opinion against the claim, the examiner opined that the Veteran’s hypertension was diagnosed about 5 years prior, in 2015, and his risk factors for developing hypertension include type 2 diabetes mellitus, obesity, high cholesterol and older age. The examiner did not address the findings of the National Academy of Sciences and the opinion also is inconsistent with notations in VA treatment records showing hypertension as early as in 2003. See February 2003 VA treatment record. Moreover, the examiner raised, but did not adequately address, an alternate (secondary service connection) theory of entitlement to service connection for hypertension (that it is secondary to his now-service-connected type 2 diabetes mellitus). As the opinion is incomplete, based on inaccurate factual premise, and not fully responsive to the Board’s remand directives, corrective action (a remand for a fully adequate medical advisory opinion) is necessary. See Stegall v. West, 22 Vet. App. 268 (1998). 2. Entitlement to service connection for multiple lipomas. The May 2018 Board remand also ordered development for a medical advisory opinion regarding the nature and likely etiology of the Veteran’s lipomas. On October 2020 VA examination, the Veteran reported he developed lipomas shortly after returning from Vietnam, in around 1970. He reported he did not know the exact dates when the lipomas were first manifested or how many developed after 2012. The examiner opined that the lipomas are less likely than not related to service, noting herbicide exposure has not been associated with the development of lipomas. The examiner did not provide a direct etiological opinion or address the Veteran’s lay statements that the lipomas first manifested upon his return from Vietnam. Accordingly, the opinion is not fully responsive to the Board’s remand directives, and corrective action (for an addendum medical advisory opinion (that is fully responsive) is necessary. See Stegall, 22 Vet. App. 268. The matters are REMANDED for the following: 1. Arrange for the Veteran’s record to be forwarded to an appropriate clinician for review and an advisory medical opinion regarding the etiology of his hypertension. [If an examination of the Veteran is deemed necessary for an opinion sought, such should be arranged.] On review of the record, the consulting provider should: (a.) Identify the likely etiology for the Veteran’s hypertension. Is it at least as likely as not (a 50 percent or greater probability) that it is etiologically related to the Veteran’s service (to include as due to exposure to Agent Orange/herbicide agents therein)? The rationale provided must address applicability of the November 2018 NAS finding upgrading the relationship between hypertension and herbicide exposure from “limited or suggestive” to “sufficient,” indicating that “there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. See National Academies of Sciences, Engineering, and Medicine. 2018. Veterans and Agent Orange: Update11 (2018). https://www.nap.edu/read/25137/chapter/12 (last accessed May2019). (b.) If hypertension is found to not be directly related to service, opine further whether it is at least as likely as not (a 50% or greater probability) that it was caused or aggravated by (increased in severity due to) his service-connected type 2 diabetes mellitus. [The opinion must address aggravation.] (c.) If a service-connected disability did not cause, but aggravated the hypertension, specify, to the extent possible, the degree of disability (symptoms/impairment) that resulted from such aggravation. (d.) If hypertension is determined to be unrelated to service/exposure to herbicide agents therein and to not have been caused or aggravated by a service-connected disability, identify the etiology for hypertension that is considered to be more likely (and explain why that is so). Include rationale with all opinions. 2. Also, arrange for the Veteran’s record to be forwarded to an appropriate clinician for review and an advisory medical opinion regarding the etiology of his lipomas. [If further examination of the Veteran is deemed necessary for an opinion sought, such should be arranged.] Upon review of the record, the consulting provider should: (a.) Identify the likely etiology for the Veteran’s lipomas. Is it at least as likely as not (a 50% or greater probability) that they are etiologically related to his service (based on onset therein reasonably shown, or as due to exposure to herbicide agents therein)? (b.) If not, identify the etiology considered for the lipomas that is considered to be more likely (and explain why that it is so). All opinions must include rationale that cites to supporting factual data and medical principles. If a requested opinion cannot be provided without resort to mere speculation, it must be so stated, with explanation why an opinion would require speculation (e.g., whether further information or testing necessary is needed for the determination; or whether the opinion could not be rendered due to limitations in the state of knowledge of the medical community at large or of the particular examiner). GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Naumovich, 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.