Citation Nr: 21020895 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 16-07 140 DATE: April 8, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to exposure to herbicide agents and/or to service-connected diabetes mellitus is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1966 to June 1969, to include in the Republic of Vietnam (Vietnam). This case comes before the Board of Veterans’ Appeals (Board) on an appeal from a May 2014 rating decision of a Department of Veterans’ Affairs (VA) Regional Office (RO). The case was remanded in September 2018 and June 2020 for additional development. 1. Entitlement to service connection for hypertension, to include as secondary to exposure to herbicide agents and/or to service - connected diabetes mellitus is remanded. The Veteran has contended that his hypertension is a result of exposure to herbicide agents during service. Alternatively, the Veteran has contended that his hypertension is secondary to his service-connected diabetes mellitus. In prior, unrelated rating decisions, the Veteran’s exposure to herbicide agents has been conceded as a result of his service in the Republic of Vietnam. The medical evidence of record also confirms that the Veteran has a current diagnosis of hypertension. Regrettably, the Veteran’s appeal must be remanded for a new medical opinion. If an examination report is inadequate or does not contain sufficient detail, the Board is required to return the report in a remand. See Bowling v. Principi, 15 Vet. App. 1, 12 (2001). A remand by the Board confers a right to compliance with the directives of that remand. See Stegall v. West, 11 Vet. App. 268 (1998). The June 2020 Board remand directed the medical examiner to specifically address National Academy of Sciences (NAS) study updates dated 2006 and 2012 which concluded that there is “limited or suggestive evidence of an association” between herbicide exposure and hypertension. In an August 2020 Medical Opinion, a VA contract examiner opined that the Veteran’s hypertension was less likely than not caused by the Veteran’s in-service exposure to herbicide agents. The rationale for the opinion was that “Agent Orange does not cause hypertension. This is established knowledge and practice.” The August 2020 examiner cited to the 2018 NAS study update indicating that while it suggested an association it did not establish cause and effect. As an initial matter the Board notes that the August 2020 examiner misstated the findings of the 2018 NAS study update which determined that there is now “sufficient” (as opposed to just “limited”) evidence to support an association between herbicide exposure and hypertension. In addition to applying the wrong NAS standard in formulating the negative nexus opinion, the examiner failed to provide an adequate explanation to support that conclusion. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board is cognizant that the NAS updates speak to associations between exposure to chemicals and health outcomes in human populations, and not to the likelihood that any individual’s health problem is associated with or caused by the herbicides in question. Thus, the question here is what is the likelihood that this Veteran’s hypertension is related to his herbicide exposure conceded by virtue of his active duty service in the Republic of Vietnam, given his deployment history, medical history, family history, and other risk factors identified in his claims file. Accordingly, the Board finds that the August 2020 medical opinion is not in substantial compliance with the June 2020 Board decision, and an additional remand for a new medical opinion is required. The matters are REMANDED for the following action: 1. Obtain any outstanding relevant VA treatment records and associate them with the claims file. 2. Following the above development, obtain a VA examination and opinion from an appropriate examiner to determine the nature and etiology of the Veteran’s hypertension. The claims folder (including a copy of this remand) must be provided to and reviewed by the examiner as part of the examination. All indicated tests should be accomplished and all clinical findings reported in detail. (a.) Is it at least as likely as not (i.e., 50 percent probability or greater) that the Veteran’s hypertension had its onset during active service, or is otherwise related to active service to include the Veteran’s presumed exposure to herbicide agents? Why or why not? The clinician should specifically address the relevance if any to the 2018 Update by the National Academy of Sciences (NAS) concluded that there is “sufficient” (as opposed to just “limited”) evidence to support an association between herbicide exposure and hypertension. Veterans and Agent Orange: Update 11 (2018), available at https://www.nap.edu/read/25137. A rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that question. Jennifer White Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Alexander 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.