Citation Nr: 21025861 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 16-22 570 DATE: April 29, 2021 REMANDED Entitlement to service connection for hypertension, for substitution purposes, is remanded. Entitlement to service connection for residuals of cerebrovascular accident, for substitution purposes, is remanded. Entitlement to special monthly compensation, for substitution purposes, is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1967 to September 1969. He had service in Vietnam. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2014 rating decision by a VA Regional Office (RO). The Board remanded these claims in a September 2018 decision to obtain new VA opinions to determine the nature and etiology of the Veteran’s hypertension and claimed cerebrovascular accident (CVA) or residuals of CVA, and to obtain VA examinations if necessary. The issue of entitlement to special monthly compensation (SMC) was remanded as inextricably intertwined with the other two. The RO scheduled examinations for hypertension and CVA. Communications received on September 19, 2019 indicate the examinations were cancelled because the Veteran failed to show. There is no indication in the record that VA notified the Veteran that the examinations had been scheduled. The RO issued a Supplemental Statement of the Case in June 2020 continuing the prior denials of the claims. The Veteran died in June 2020. The Appellant claims as the Veteran's surviving spouse. Within a year of his death, the Appellant filed an Application for Dependency and Indemnity Compensation, Death Pension, and/or Accrued Benefits, which was treated as a request for substitution. See 38 C.F.R. § 3.1010 (c)(2). We note that a July 2020 rating decision granted service connection for the Veteran’s cause of death as due to his service-connected type II diabetes mellitus. The RO granted the Appellant’s request to be substituted in the Veteran’s appeal and informed her of the decision by letter in August 2020. Accordingly, the Appellant has been substituted as the claimant for purposes of adjudicating the issue on appeal to completion. See 38 U.S.C. § 5121A. New VA nexus opinions regarding the etiology of the Veteran’s hypertension and CVA were obtained in September 2020. The matters return to the Board for further adjudication. 1. Service connection for hypertension. The Veteran primarily contended that hypertension was secondary to his service-connected type II diabetes mellitus. He also asserted that hypertension was directly related to his service and that he had high blood pressure and fainting spells within one year of separation from service. With regard to the Veteran’s contention that his hypertension is related to service, the Board notes that his service treatment records are absent complaints of or treatment for high blood pressure or hypertension specifically, but the Veteran did report a history of dizziness and fainting spells on the September 1969 report of medical history when he separated from service. The Veteran’s service personnel records verify his service in Vietnam from October 1968 to August 1969. He is presumed to have been exposed to herbicides in service, as VA has already established. We note that the Veteran was service connected for his type II diabetes mellitus due to his presumed exposure to herbicides. There are VA nexus opinions regarding service connection for hypertension. In the September 2018 remand, the Board determined that the April 2014 opinion was inadequate because it was based on an inaccurate factual premise and did not address the Veteran’s claim on a direct incurrence theory, and remanded the claim to obtain a new VA opinion. A new VA opinion was obtained in September 2020. The examiner determined hypertension was not caused by service, was not caused by a service-connected condition, and was not caused by the reported event of elevated blood pressure and syncope that occurred a year after service. The examiner explained that an event of symptomatic elevated hypertension will have caused a cardiology evaluation and as likely the institution of medication at that time, and that based on all medical records available, this was not the case. Based on later medical notes and stated by the Veteran in an April 2010 VA examination, he was diagnosed with hypertension in early 1990. As per medical literature, blood pressure reacts to changes in the environment to maintain organ perfusion over a wide variety of conditions. The primary factors determining the blood pressure are the sympathetic nervous system, the renin-angiotensin-aldosterone system, and the plasma volume (largely mediated by the kidneys). Therefore, based on scientific information or model, it is expected that blood pressure will be abnormal under the effect of an out of ordinary situation. This does not constitute a medical condition, but rather a normal physiological variation. The examiner cited medical literature stating that the pathogenesis of primary hypertension is poorly understood but is most likely the result of numerous genetic and environmental factors that have multiple compounding effects on cardiovascular and renal structure and function. The examiner concluded that primary essential hypertension is a known diagnosis with a multifactorial etiology, predominantly genetic, and commonly of adult onset in the general population. The examiner concluded there is no objective evidence to support that hypertension was aggravated in any measurable way beyond its natural progression by the Veteran’s service-connected diabetes mellitus, and that there is no objective evidence to support that hypertension was aggravated in any measurable way by military service that preceded the condition. Much of the September 2020 rationale addresses the Veteran’s statements that he experienced fainting spells and high blood pressure within one year of separation from service, and that such would not constitute a medical condition but rather a normal physiological variation in blood pressure. Little of the provided rationale addresses whether diabetes mellitus aggravated the Veteran’s hypertension. While there is no reasons-or-bases requirement imposed on examiners, they must support their conclusions with an analysis that the Board can consider and weigh. See Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). We also note there is evidence the Veteran had symptoms relating to hypertension for years prior to the 1990 date of diagnosis cited by the examiner. The first documented diagnosis of hypertension is contained in a VA Form 10-9034a Medical Record Report dictated and typed in December 1989. A long history of high blood pressure was documented, and the Veteran reported that he had been prescribed blood pressure medicines but was unable to afford them. He was discharged from the hospital in December 1989 with a hypertension diagnosis. Crucially, the Board notes that in Veterans and Agent Orange: Update 11 (2018), the National Academies of Sciences, Engineering and Medicine (NAS) found sufficient evidence of an association for hypertension and exposure to Agent Orange and other herbicides used during the Vietnam War. Further, hypertension was upgraded from its previous classification in the category of “limited or suggestive” evidence of an association to the category of “sufficient” evidence of an association. According to NAS, “[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. There are no medical opinions addressing the 2018 NAS Veterans and Agent Orange update finding sufficient evidence of an association between hypertension and exposure to Agent Orange and other herbicides used in the Vietnam War. We do acknowledge that VA examiners had not previously been instructed to address the report. The September 2020 examiner did cite medical literature indicating environmental factors could contribute to the etiology of hypertension. Under these circumstances, the Board finds that a new medical opinion should be obtained addressing the etiology of the Veteran’s hypertension 2. Service connection for cerebrovascular accident and/or residuals thereof is remanded. 3. Entitlement to SMC is remanded. We note that the Veteran generally contended that he became incapable of walking and lost the use of his upper extremities following his June 2013 stroke. See, e.g., August 2014 Notice of Disagreement. Resolution of the service connection claims discussed above may have an impact on the Veteran’s claim for SMC. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Remand of the claim for SMC is required. The matters are REMANDED for the following action: 1. Forward the Veteran’s claims file to a VA examiner with the appropriate expertise for a medical opinion to determine the etiology of his hypertension. The examiner should respond to the following: a. Whether the Veteran’s hypertension was at least as likely as not (50 percent probability or greater) related to his service, to include his presumed exposure to herbicides in Vietnam. In making this determination, the examiner should address the NAS updates which concluded that there was “sufficient” evidence of an association between hypertension and herbicide exposure. b. Whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s hypertension was caused by or increased in severity beyond natural progression by service-connected diabetes mellitus. If diabetes mellitus aggravated the hypertension, the examiner should identify the percentage of disability which is attributable to the aggravation. 38 C.F.R. § 3.310. 2. Readjudicate the Appellant’s claims, to include entitlement to Special Monthly Compensation. If the benefits sought on appeal are not granted, the Appellant should be provided a Supplemental Statement of the Case and afforded the requisite opportunity to respond before the case is returned to the Board. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Morse 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.