Citation Nr: 21026566 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 13-20 905 DATE: May 3, 2021 REMANDED The issue of service connection for hypertension as secondary to service-connected posttraumatic disorder or due to exposure to herbicide agents is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1967 to October 1969, to include service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2012 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the Board in a videoconference hearing in August 2011. A copy of the hearing transcript is associated with the claims file. This matter was previously before the Board and remanded for further development in November 2017 and July 2020. 1. Service connection for hypertension as secondary to service-connected posttraumatic disorder or due to exposure to herbicide agents is remanded. The Veteran contends that his hypertension is (1) related to conceded exposure to herbicide agents during service in Vietnam, or (2) proximately caused or aggravated by service-connected PTSD. This claim was remanded in November 2017, in part, to obtain an examination and medical opinion to determine the nature and etiology of the Veteran's hypertension. The Board directed the examiner to consider and address a National Academy of Sciences (NAS) report finding "limited or suggestive evidence of an association" between hypertension and herbicide exposure. See Determinations Concerning Illnesses Discussed in National Academy of Sciences Report: Veterans and Agent Orange: Update 2010, 77 Fed. Reg. 47,924, 47,926 (Aug. 10, 2012); Notice on Health Outcomes Not Associated With Exposure to Certain Herbicide Agents, 75 Fed. Reg. 32,540, 32,542 (June 8, 2010). The Veteran was afforded an examination in February 2019. The examiner rendered a negative nexus opinion and determined that the Veteran's hypertension was less likely than not secondary to service or agent orange exposure. February 14, 2019, VA Examination. The examiner reasoned that there was no evidence in the literature or studies that show a cause and effect relationship between agent orange exposure and hypertension. Id. He further stated that although there is limited evidence suggesting an association, this is only an association and in no way proves a causal relationship. Id. The Board finds that the February 2019 VA medical opinion is inadequate for adjudication purposes as it is based on an inaccurate factual premise. See Reonal v. Brown, 5 Vet. App. 458 (1993) (a medical opinion based on an inaccurate factual premise is not probative). The medical opinion is based on the premise that there is only limited or suggestive evidence of an association between hypertension and herbicide agent exposure. However, NAS upgraded hypertension from its previous classification in the category of "limited or suggestive" evidence of an association with exposure to herbicides to the category of "sufficient" evidence of an association in Veterans and Agent Orange: Update 11 (2018). 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. The report more specifically explains that "a positive association has been observed between exposure to herbicides and the outcome in studies in which chance, bias, and confounding could be ruled out with reasonable confidence." Once VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311. Remand is necessary to obtain an addendum medical opinion. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion from the appropriate clinician to determine the nature and etiology of the Veteran's hypertension. The clinician should review the claims file and address the following: 2. Whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's hypertension manifested in or is otherwise related to his period of active service, to specifically include his exposure to herbicides. (Continued on the next page) The examiner is advised to acknowledge and consider the National Academy of Sciences Institute of Medicine's 2018 update in which NAS concluded that there was sufficient evidence of a positive association between hypertension and exposure to herbicides. A rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Monica Ball Jackson, 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.