Citation Nr: 21020898 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 15-15 598 DATE: April 8, 2021 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for erectile dysfunction is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1965 to September 1967. In August 2019, the Board remanded this case for additional development. The Board finds that there has not been substantial compliance with the Board’s previous remand directives. Remand for further development is required. Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for hypertension is remanded. In April 2019, the Board requested a medical opinion which addressed whether hypertension was: (1) related to service, to include herbicide agent exposure; (2) caused by any service-connected disability or treatment for any service-connected disability; or (3) aggravated by any service-connected disability or treatment for any service-connected disability. The Board noted that the National Academy of Sciences (NAS) Institute of Medicine’s Veterans and Agent Orange: Update 2010, concluded that there is “limited or suggestive” evidence of an association between exposure to herbicide agents and hypertension, and that should be considered in any opinion as to whether hypertension may be related to active service. In a February 2020 medical opinion, the examiner opined that hypertension was not related to presumed herbicide exposure because “veterans exposed to agent orange/herbicides are granted presumptive service connection for various conditions but not hypertension yet.” The examiner opined that hypertension was not secondary to PTSD because “there [was] no evidence of persistent high blood pressure since military service related to PTSD.” The examiner opined that hypertension was not aggravated by any service-connected disability because it was “[n]ot feasible to assess what extent other condition may affect his blood pressure as his hypertension is overall controlled with medications.” The Board finds the examiner's opinion incomplete. The Board notes that a negative opinion regarding a relationship between hypertension and exposure to herbicide agents based solely on the fact that VA has not recognized hypertension as a presumptive disease related to herbicide exposure is not adequate. The examiner did not discuss or reconcile the opinion with the NSA finding which does not rule out a connection between hypertension and exposure to herbicide agents. There was no rationale with references to general medical knowledge or medical literature to support the conclusion. In concluding that hypertension was not secondary to PTSD, the examiner did not discuss the significance of a lack of persistent high blood pressure readings associated with PTSD. There are no opinions regarding whether hypertension was secondary to medication for PTSD symptoms; whether hypertension was secondary to diabetes mellitus or medications for diabetes; or whether hypertension was secondary to ischemic heart disease medications. The examiner provided an opinion on the baseline level of severity for erectile dysfunction. However, there is no opinion regarding whether hypertension was aggravated by any service-connected disability or medication used to treat any service-connected disability. When VA provides an examination or obtains an opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). In order to be entitled to probative weight, a medical opinion must contain not only clear conclusions with supporting data, but also a reasoned explanation connecting the two. Nieves-Rodrigues v. Peake, 22 Vet. App. (2008). A remand confers on the Veteran the right to compliance with the terms of that remand. Stegall v. West, 11 Vet. App. 268 (1998). Because of the deficiencies in the February 2020 opinion, remand is necessary. 2. Entitlement to service connection for erectile dysfunction is remanded. The Board requested a medical opinion which addressed whether erectile dysfunction was related to service, to include herbicide agent exposure; caused by any service-connected disability or treatment for any service-connected disability; or aggravated by any service-connected disability or treatment for any service-connected disability. In a February 2020 medical opinion, the examiner opined that erectile dysfunction was not related to presumed herbicide exposure because “erectile dysfunction [began in] 2010. No evidence of erectile dysfunction during service.” The examiner opined that erectile dysfunction was not related to herbicide agent exposure because “Veterans exposed to agent orange/herbicides are granted presumptive service connection for various conditions but not erectile dysfunction.” The examiner stated that erectile dysfunction was not secondary to diabetes mellitus or PTSD because erectile dysfunction and diabetes mellitus were both diagnosed in 2010; and PTSD was “stable with medication but no improvement of [the] erectile dysfunction, PTSD is unlikely cause for his persistent erectile dysfunction.” The Board finds the examiner's opinion inadequate for adjudication purposes. A negative opinion regarding a relationship between erectile dysfunction and service based on the absence of medical records without consideration of a Veteran's competent reports is incomplete. Buchannan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Likewise, a negative opinion regarding a relationship between erectile dysfunction and exposure to herbicide agents based solely on the fact that VA has not recognized erectile dysfunction as a presumptive disease related to herbicide exposure is not adequate. The examiner did not provide a rationale with references to general medical knowledge or medical literature to support the conclusions. The examiner did not provide a clearly stated rationale with references to the record, diagnostic tests, medical literature, etc. to support the conclusion that erectile dysfunction was not secondary to any service-connected disability or treatment for used for a service-connected disability. The examiner did not provide an opinion on whether erectile dysfunction was aggravated by PTSD or medications for PTSD symptoms. When VA provides an examination or obtains an opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). A remand confers on the Veteran the right to compliance with the terms of that remand. Stegall v. West, 11 Vet. App. 268 (1998). Because of the deficiencies in the February 2020 opinion, remand is necessary. The matters are REMANDED for the following action: 1. After obtaining any necessary releases, obtain all relevant VA and private treatment records not already associated with the claims file. All attempts to locate records must be documented in the claims file. 2. Schedule the Veteran for a VA examination with a medical doctor who has not previously examined him in conjunction with this claim, to determine the nature and etiology of hypertension. The examiner must review the claims file and note the review in the report. The examiner must identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge, or literature, etc., relied upon in reaching all conclusions. The examiner must opine whether: (a.) Opine whether it is at least as likely as not (50 percent or greater probability) that hypertension is related to active service or any event, disease, or injury during service, including herbicide agent exposure. The examiner is advised that a negative opinion regarding a relationship between hypertension and exposure to herbicide agents based solely on the fact that VA has not recognized hypertension as presumptive diseases related to herbicide exposure is not an adequate opinion. The examiner must consider and discuss the National Academy of Sciences (NAS) Institute of Medicine’s Veterans and Agent Orange: Update 2010, which concluded that there is “limited or suggestive” evidence of an association between exposure to herbicide agents and hypertension. (b.) Opine whether it is at least as likely as not (50 percent or greater probability) that hypertension was caused by any service-connected disability or treatment for any service-connected disability. The examiner should explain why or why not. The examiner is advised that the Veteran is service connected for ischemic heart disease, diabetes mellitus, and PTSD. A clearly stated rationale must be provided. The examiner must explain the relevance or significance of any history, clinical findings, medical knowledge, or literature relied upon in reaching the conclusion. (a.) Opine whether it is at least as likely as not (50 percent or greater probability) that hypertension has been aggravated (increased in severity beyond the natural progress of the disorder) by any service-connected disability or treatment for any service-connected disability, to include ischemic heart disease, diabetes mellitus, and PTSD. The examiner should explain why or why not. 3. Schedule the Veteran for a VA examination with a medical doctor who has not previously examined him in conjunction with this claim, to determine the nature and etiology of erectile dysfunction. The examiner must review the claims file and note the review in the report. The examiner must identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge, or literature relied upon in reaching all conclusions. The examiner should provide the following: (a.) Opine whether it is at least as likely as not (50 percent or greater probability) that erectile dysfunction is related to active service or any event, disease, or injury during service, including herbicide agent exposure. The examiner is advised that a negative opinion based on the absence of medical records without consideration of a Veteran's competent reports is incomplete. A negative opinion based solely on the fact that VA has not recognized erectile dysfunction as a presumptive disease related to herbicide agent exposure is not an adequate opinion. (b.) Opine whether it is at least as likely as not (50 percent or greater probability) that erectile dysfunction was caused by a service-connected disability or treatment for a service-connected disability. The examiner should explain why or why not. The Veteran is service connected for ischemic heart disease, diabetes mellitus, and PTSD. A clearly stated rationale must be provided. The examiner must explain the relevance or significance of any history, clinical findings, medical knowledge, or literature relied upon in reaching the conclusion. (c.) Opine whether it is at least as likely as not (50 percent or greater probability) that erectile dysfunction has been aggravated (increased in severity beyond the natural progress of the disorder) by any service-connected disability or treatment for any service-connected disability, to include ischemic heart disease, diabetes mellitus, and PTSD. The examiner should explain why or why not. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E.O., 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.