Citation Nr: 21023511 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 14-41 947 DATE: April 20, 2021 REMANDED Entitlement to service connection for hypertension, to include as due to herbicide exposure and/or as secondary to service-connected diabetes mellitus type II, is remanded. REASONS FOR REMAND The Veteran served honorably in the United States Army from December 1965 to December 1958. This issue comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran contends that his hypertension is the result of military service, including in-service herbicide exposure. In addition, he contends that his hypertension was caused or aggravated by his service-connected diabetes. The Board notes that this matter was remanded in May 2018 for a new VA examination regarding the etiology of the Veteran’s hypertension. The Board noted that the previous examiner did not address whether the hypertension could be related to in-service herbicide exposure. In addition, the examiner failed to provide any rationale that the hypertension was not aggravated by the Veteran’s service-connected diabetes. The Veteran underwent a VA examination in October 2019. He was diagnosed with hypertension. The examiner then gave a positive nexus opinion that the hypertension was the result of military service, including herbicide exposure. In support of this opinion, the examiner cited the following medical literature: Toxic Epidemics: Agent Orange Sickness in Vietnam and US-Medical anthropology 2016. The examiner then gave a negative opinion that the hypertension was aggravated by the service-connected diabetes, stating that the previous VA examiner concluded that the hypertension and diabetes were diagnosed at the same time. No other opinions or rationale were provided. An addendum VA opinion was issued in March 2020. The examiner gave a negative opinion that the hypertension was the result of military service. The examiner noted that a review of the service treatment records (STRs) showed no complaints or diagnosis of hypertension. In addition, the examiner noted that “VA does not list HTN (hypertension) as presumptive to AO (Agent Orange) exposure.” She then gave a negative opinion that the hypertension was aggravated by the service-connected diabetes. She noted that the records were silent for worsening of hypertension since his diabetes diagnosis in 2003. A clarifying addendum VA opinion was issued in May 2020. The examiner gave a negative opinion that the hypertension was the result of military service. She noted that a review of the STRs revealed no diagnosis of hypertension during service or within one year of discharge. In addition, she noted that there was no medical evidence provided to support the hypertension being caused by herbicide exposure. The examiner then gave a negative opinion that the hypertension was aggravated by the service-connected diabetes. She noted that the hypertension was diagnosed in 1983 and the diabetes was diagnosed in 2003. She also noted that the record was silent for worsening of hypertension since the diabetes diagnosis. No other opinions or rationale were provided. The VA has a duty to assist veterans in developing their claims for benefits. 38 C.F.R. § 3.159. The duty to assist including providing a medical examination when necessary to decide a claim. 38 C.F.R. § 3.159 (c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA opinions are inadequate for adjudicative purposes. The VA examiner based her negative direct service connection opinion on a lack of medical evidence. However, the Veteran’s previous representative cited a 2006 update by the National Academy of Science (NAS) changing the categorization of hypertension to “limited or suggestive evidence” that suggests an association between herbicide exposure and hypertension. In addition, the previous VA examiner cited medical literature in support of a positive nexus opinion. However, the examiner did not consider or discuss this evidence. Regarding the aggravation opinion, the examiner found that the records were silent as to any worsening of the Veteran’s hypertension as a result of his diabetes. However, the evidence of record demonstrates that his hypertension medication has increased from one medication to three medications and with increased dosages since his diabetes diagnosis. Again, the examiner failed to consider this evidence in rendering her opinion. Based on the inadequacies of the VA medical opinions, the Board must remand this matter for the issuance of an addendum VA medical opinion that addresses all the evidence of record. The matter is REMANDED for the following action: 1. Obtain updated VA and/or private treatment records to the extent possible. If such records are unavailable, the Veteran's claims file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159 (e). 2. Once the above has been completed to the extent possible, obtain a VA medical opinion regarding the Veteran’s hypertension from a medical professional with appropriate expertise. The examiner should review the Veteran’s claims file and make a notation that the claims file was reviewed. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one (or a telehealth interview if an in-person examination is not feasible). Based on a review of the record, and a new examination if necessary, the examiner must address the following: (a.) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s hypertension had its onset in service or is otherwise related to service, including presumed herbicide exposure? In rendering this opinion, the examiner must address and discuss the 2006 NAS update of the categorization of hypertension, as well as the following medical literature: Toxic Epidemics: Agent Orange Sickness in Vietnam and US-Medical anthropology 2016. (b.) Whether it is at least as likely as not that the Veteran’s hypertension was caused or aggravated by the Veteran’s service-connected disabilities, including but not limited to: his diabetes? The examiner must render opinions on both causation and aggravation. In addition, the examiner must address the medical evidence of record demonstrating an increase in hypertension medication since the 2003 diabetes diagnosis. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. “Aggravation” means any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease, and not due to the natural progress of the nonservice-connected disease. If aggravation is found, the examiner should attempt to quantify the extent of additional disability resulting from the aggravation. In rendering this opinion, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the medical professional rejects the Veteran’s reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran’s lay statements or rely solely on an absence of medical evidence in the record to support his or her conclusions. A complete rationale must be provided for all opinions presented. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional 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 particular question(s). Saudiee Brown Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J.T. Massey, 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.