Citation Nr: 21025997 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 12-28 366 DATE: April 29, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to herbicide exposure is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1966 to August 1970. The Veteran attended a hearing before the undersigned Veterans Law Judge in May 2016. A transcript of the hearing is of record. This matter was previously remanded by the Board of Veterans’ Appeals (Board) in June 2016 and April 2018. Entitlement to service connection for hypertension, to include as secondary to herbicide exposure is remanded. The Veteran contends that his current hypertension condition is related to his active service. Specifically, the Veteran contends that his hypertension was directly caused by his conceded exposure to herbicides during his service at U-Tapao Air Force Base, Thailand, while working near the perimeter. In accordance with the April 2018 Board remand, the Veteran had an examination for his hypertension in September 2019. The examiner opined that it was less likely than not that the Veteran’s hypertension was incurred in or caused by his active duty service, to include as a result of his presumed exposure to herbicides. The examiner noted that the Veteran’s service treatment records do not demonstrate a diagnosis of or treatment for hypertension. Furthermore, the examiner noted the National Academy of Sciences (NAS) Report: Veterans and Agent Orange: Update 2012, which notes “limited or suggestive” evidence of a relationship between hypertension and herbicide exposure. Additionally, the examiner noted that there were some studies indicating a possible link between herbicide exposure particularly in Army chemical corps members and in USAF enlisted ground crew members with participation in Operation Ranch Hand. However, the examiner noted that these studies many of these studies involved small numbers of participants, self-reported data or lacked analysis taking into account family history and lifestyle factors such as smoking history, nicotine use, alcohol use etc. Furthermore, the examiner noted that there is no scientifically reviewed medical literature found that definitively links herbicide exposure and hypertension. The Board finds the September 2019 examiner’s opinion to be insufficient. In the time since the Board’s last remand, the NAS has upgraded the relationship between hypertension and herbicide exposure from “limited or suggestive” to “sufficient,” indicating that “there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. Although the September 2019 examiner noted that there are “some studies indicating a possible link between herbicide exposure” and hypertension, it is not clear whether the examiner fully considered the November 2018 NAS study. Accordingly, the Board finds the remand is warranted for an addendum medical opinion regarding the etiology of the Veteran’s hypertension in light of the November 2018 NAS study. The matters are REMANDED for the following action: Obtain an addendum medical opinion from a qualified VA medical professional to determine whether the Veteran’s hypertension was related to his military service, including his presumed exposure to herbicides. The record must be made available to and reviewed by the VA examiner. Any indicated evaluations, studies, and tests should be conducted. Following a review of the entire record, the examiner should address the following: Is it at least as likely as not (i.e., a 50 percent or greater probability) that a claimed hypertension disability had its onset in, or is otherwise related to his period of active duty service, to include his presumed exposure to herbicides? The examiner is specifically requested to discuss that in November 2018, the National Academy of Sciences upgraded the relationship between hypertension and herbicide exposure from “limited or suggestive” to “sufficient,” indicating that “there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. See National Academies of Sciences, Engineering, and Medicine. 2018. Veterans and Agent Orange: Update 11 (2018). https://www.nap.edu/read/25137/chapter/12 (last accessed April 2021). The examiner is informed that the mere fact that a VA presumption has not been established for a particular disorder at issue is not dispositive of the issue of nexus and consideration must still be given to the exposure. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner should note that the lack of a diagnosed hypertension disability in service cannot serve as the sole basis for a negative finding. Lay contentions must be considered and weighed in making the determination as to whether a nexus exists. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board David M. Sebstead, 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.