Citation Nr: 21023277 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 17-13 916A DATE: April 20, 2021 REMANDED Entitlement to service connection for hypertension, to include as due to herbicide agent exposure or secondary to service-connected disabilities, is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected disabilities, is remanded. Entitlement to service connection for sleep apnea, to include as secondary to service-connected disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from March 1966 to February 1969 and from June 1973 to August 1973. The Board of Veterans’ Appeals (Board) remanded the matter in October 2020 to obtain additional medical opinions. Inasmuch as the Board regrets any further delay in the final adjudication of this appeal, additional development is needed, and a remand is necessary to fully address all issues on appeal 1. Entitlement to service connection for hypertension, to include as due to herbicide agent exposure or secondary to service-connected disabilities, is remanded. The Veteran asserts that his hypertension is related to his active duty service. Specifically, he contends that it is either secondary to or aggravated by his service-connected diabetes mellitus, type II or posttraumatic stress disorder (PTSD), or it is due to exposure to Agent Orange exposure during service. The Board remanded this matter in October 2020 to obtain an addendum opinion as to whether the Veteran’s hypertension was caused or aggravated by his service-connected disabilities, or in the alternative, directly by active service. In January 2021, a VA opinion was obtained. While that opinion discussed secondary considerations in detail, with regard to the question of direct service connection, the examiner stated that the Veteran’s hypertension could not be caused by service because there was no diagnosis of hypertension during active service or within one year of separation therefrom. It did not discuss the Veteran’s contention that his hypertension is related to herbicide exposure, as was implied in the prior remand orders. The National Academy of Sciences Institute of Medicine has concluded that there is “limited or suggestive evidence of an association” between herbicide exposure and hypertension. See 77 Fed. Reg. 47924, 47926-927 (Aug. 10, 2012). Additionally, a recent determination from the National Academy of Sciences upgraded hypertension to the “sufficient” category from “limited or suggestive,” indicating that “there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. See Veterans and Agent Orange: Update 11 (2018) (available at http://nationalacademies.org/hmd/reports/2018/veterans-and-agent-orange-update-2018.aspx). As a result, the Board will remand this appeal so that an opinion may be obtained that fully addresses the question of whether the Veteran’s present hypertension is related to his in-service herbicide exposure. 2. Entitlement to service connection for GERD, to include as secondary to service-connected disabilities, is remanded. The Board’s 2020 remand order sought addendum opinions on whether the Veteran’s GERD was related to active duty service, to include as secondary to his service-connected conditions because the previous VA examiners from August and December 2016 did not provide adequate reasons and bases for their opinions. Specifically, in August 2016, the VA examiner indicated that the Veteran has a diagnosis of GERD, but opined that GERD has no etiologic relationship to diabetes mellitus, type II or PTSD. An addendum opinion the same month states that the Veteran’s GERD is mild and is not associated with diabetic gastropathy because the Veteran’s diabetes is well controlled and there is no peripheral neuropathy. In December 2016, a VA examiner opined that there are no objective findings on the esophagus consistent with GERD, and a September 2008 EGD revealed a normal esophagus. However, the Veteran was diagnosed with and treated for erosive gastritis. The examiner did not provide an opinion for GERD as “there is no pathology to render a diagnosis.” However, the examiner also noted that no diagnostic studies were performed and recommended that the Veteran follow-up with a primary medical doctor for further evaluation because “low Hb and low Ht” are of unclear etiology but are possibly due to erosive gastritis. The examiner seemingly did not attempt to ascertain the Veteran’s current gastric or intestinal diagnosis by conducting diagnostic testing. Next, in January 2021, the VA examiner opined that the Veteran’s GERD is less likely than not related to active duty service because there is no object evidence of GERD in the record, despite acknowledging the Veteran was diagnosed with gastritis via EGD in 2008. The examiner did not provide a secondary medical opinion because they determined there is no current diagnosis of GERD. The examiner did not determine whether the Veteran has any other gastroesophageal disabilities, and if so, whether they are related to service or the Veteran’s other service-connected disabilities. Given the general confusion regarding the Veteran’s diagnosis of GERD or some other gastroesophageal disability, a new examination is required to determine whether the Veteran has a current diagnosis of gastric or esophageal conditions, to include GERD or corrosive gastritis. As the December 2016 VA examiner acknowledged that the Veteran may currently have corrosive gastritis and follow-up testing should be done, a new examination with appropriate diagnostic testing should be ordered, and if any gastroesophageal diagnosis is given, etiology opinions should be obtained. 3. Entitlement to service connection for sleep apnea, to include as secondary to service-connected disabilities, is remanded. The Veteran contends that his sleep apnea is caused or aggravated by his service-connected diabetes mellitus, type II or PTSD or its medications. In January 2021, a VA examiner opined that it is less likely than not that the Veteran’s sleep apnea is the result of the Veteran’s service-connected condition and noted that being overweight is the single most significant risk factor for developing obstructive sleep apnea. In March 2021, the Veteran submitted an article discussing the connection between PTSD and weight gain. The Veteran contends that his weight gain was likely caused by his service-connected PTSD. Because the examiner opined that the Veteran’s sleep apnea was likely caused by weight-gain, an opinion is required to determine whether the Veteran’s service-connected disorders likely caused or aggravated his weight gain, which, in turn, likely caused or aggravated his sleep apnea. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate examiner discussing whether the Veteran’s hypertension is at least as likely as not (i.e. a 50 percent or greater probability) related directly to his active duty service, and in particular, to his exposure to toxic herbicides. A complete rationale should be given for the opinion rendered. The examiner is reminded that a lack of diagnosis in service or within one year of separation alone is inadequate to support the conclusion, and any discussion should include consideration of herbicide exposure explicitly. The need for a new examination is left to the discretion of the examiner giving the opinion. 2. Schedule the Veteran for a VA examination for his gastroesophageal disability (to include his claim of GERD). The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion(s) below. Should no diagnosis or actual disability be found, the examiner should provide a discussion as to how that conclusion was reached. If a diagnosed gastroesophageal disability is identified, the examiner is asked to provide a response to the following: Is the Veteran’s gastroesophageal disability at least as likely as not related to service, including any herbicide exposure during active service. In the alternative, the examiner should state whether the disability is at least as likely as not (a) proximately due to or (b) aggravated, i.e., worsened beyond its natural progression, by his service-connected PTSD or diabetes mellitus, type II. A discussion and rationale should be provided for all opinions given. 3. Obtain an addendum opinion from an appropriate clinician as to whether the Veteran’s weight gain is at least as likely as not (a) caused or (b) aggravated by his service-connected disabilities, to include PTSD and diabetes mellitus, type II. Specifically, the examiner should note the January 2021 opinion linking the Veteran’s current sleep disability to weight gain, and also review the article submitted by the Veteran in March 2021 relating PTSD to weight gain. If the examiner determines that the Veteran’s weight gain is at least as likely as not related to his active duty service or is caused or aggravated by his service-connected disabilities, the examiner should provide an opinion as to whether the Veteran’s sleep apnea is at least as likely as not (i.e. a 50 percent or greater probability) either (a) caused or (b) aggravated by his service-connected disabilities. A complete rationale for any opinion expressed should be provided. The need for a new examination is left to the discretion of the examiner selected to give the opinion. M. Pryce Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Veltri, 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.