Citation Nr: 21021754 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 14-42 361 DATE: April 13, 2021 REMANDED Entitlement to service connection for hypertension as secondary to coronary artery disease or alternatively as secondary to herbicide agent exposure is remanded. REASONS FOR REMAND The Veteran served honorably in the United States Marine Corps from July 1966 to July 1969. Although the Board regrets the delay, remand is required to ensure there is a complete record on which to decide the Veteran’s claim. The Board acknowledges that this claim has been remanded twice previously in April 2018 and August 2020. However, in order to afford the Veteran complete due process, an additional remand is required. Entitlement to service connection for hypertension to include as secondary to coronary artery disease or herbicide agent exposure is remanded. The Veteran has contended several theories of entitlement to service connection for hypertension. In July 2012, the Veteran stated he believed his hypertension was due to herbicide agent exposure. At the November 2017 Board hearing and in the July 2020 Veteran’s statement, the Veteran contended his hypertension was due to stress incurred during combat in service. Finally, also at the November 2017 Board hearing, the Veteran alleged his hypertension was secondary to his service-connected coronary artery disease. In July 2013, the Veteran’s private physician, Dr. B.D., stated that there is no way to know for sure if dioxin exposure was the cause of the Veteran’s hypertension. The doctor further stated that the Veteran’s aggressive cardiovascular disease and having been exposed to dioxins raises a legitimate concern. In July 2013, the Veteran submitted press release from the National Academy of Sciences which stated data suggests a possible association between agent orange exposure and hypertension. In April 2018, the Board remanded the Veteran’s claim for entitlement to service connection for hypertension to obtain a medical opinion regarding the relationship between the Veteran’s currently diagnosed hypertension and service, herbicide agent exposure, and the service-connected coronary artery disease. In January 2019, the Veteran was seen for a VA examination for hypertension. The examiner provided it is less likely than not that the currently diagnosed hypertension was related to military service or secondarily related to or aggravated by the service-connected coronary artery disease. The examiner provided that the Veteran’s hypertension was not established until 1995, which was many years after service, so it was less likely than not related to service. Further, the examiner stated that the Veteran’s hypertension pre-dated the Veteran’s coronary artery disease, so thereby it was not caused or aggravated by the coronary artery disease. In August 2020, the Board found the January 2019 inadequate for resolving the appeal. The examiner failed to address the Veteran’s July 2013 treating physician’s letter as directed in the April 2018 Board remand. Further, the examiner did not provide clear rationale as to why the examiner felt the Veteran’s coronary artery disease did not aggravate the Veteran’s hypertension. In November and December 2020, a VA examiner provided several statements regarding the Veteran’s claim for service connection for hypertension. The examiner provided opinions regarding the Veteran’s lay contention that the stress of service caused his hypertension and provided an opinion regarding the relationship between the Veteran’s coronary artery disease and hypertension. Unfortunately, the Board finds the question of the relationship between the Veteran’s hypertension and exposure to herbicide agents remains unresolved. The January 2019 VA examiner opined the Veteran’s hypertension started many years after service and was thereby unrelated to herbicide agent exposure. However, the January 2019 VA examiner did not address the July 2013 private physician statement that the Veteran’s exposure to herbicide agents was a legitimate concern. Further, the examiner did not address the submitted press release from the National Academy of Sciences which stated data suggests a possible association between agent orange exposure and hypertension. Finally, the Board notes that although hypertension is not currently among the diseases which have been presumptively linked to herbicide exposure under 38 C.F.R. § 3.309(e), the National Academies of Sciences, Engineering, and Medicine (NAS) upgraded the likelihood of an association between hypertension and exposure to herbicides, to include Agent Orange, from “limited or suggestive” evidence of an association to “sufficient” evidence of an association. See Veterans and Agent Orange: Update 11 (2018) (available at http://nationalacademies.org/hmd/reports/2018/veterans-and-agent-orange-update-2018.aspx). Given the NAS findings discussed above, the Board finds that a VA examination and medical opinion should be provided to evaluate the Veteran’s claim. Accordingly, a remand is required. The matters are REMANDED for the following action: 1. Ask the appropriate examiner to review the Veteran’s file regarding hypertension. The necessity of an in-person examination, with any appropriate testing, is left to the discretion of the examiner. The entire claims file must be made available to the designated examiner, including this remand. The examiner is asked to respond to the following: (a.) Whether the Veteran’s hypertension is at least as likely as not related to in-service herbicide agent exposure. The examiner should note that herbicide agent exposure has been conceded. In providing the requested opinion the examiner must specifically address the following: i. The November 2018 Veterans and Agent Orange: Update 11, citing a recent NAS report indicating that there is “sufficient” evidence of an association between hypertension and herbicide agent exposure. ii. The opinion of Dr. B.D. dated July 11, 2013. iii. The Veteran submitted press release from the National Academy of Sciences which stated data suggests a possible association between agent orange exposure and hypertension. See July 2012 Veteran’s submission. (CONTINUED ON THE NEXT PAGE)   The examiner should set forth all findings, along with the complete rationale for any conclusions reached. A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Laura C. Owens 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.