Citation Nr: 21028886 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 19-31 455 DATE: May 12, 2021 REMANDED Service connection for diabetes mellitus II (diabetes), including as due to herbicide exposure, is remanded. Service connection for hypertension, including as due to herbicide exposure, to include as secondary to posttraumatic stress disorder (PTSD) and diabetes, is remanded. Service connection for aortic aneurysm, including as due to herbicide exposure, to include as secondary to PTSD, hypertension, and diabetes is remanded. REASONS FOR REMAND The Veteran had active duty service from December 1968 to September 1970, including service in the Republic of Vietnam. Accordingly, VA has acknowledged the Veteran's exposure to herbicide agents. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board acknowledges that the Veteran has also perfected an appeal regarding the issue of an increased rating for his PTSD. However, the Veteran requested a Board hearing which has not yet been scheduled. See May 2016 VA Form-9 Therefore, the issue will be addressed in a separate Board decision following the requested hearing. 1. Entitlement to service connection for diabetes, including as due to herbicide exposure The Veteran contends that he suffers from diabetes as a result of his acknowledged exposure to herbicide agents while serving in the Republic of Vietnam. The claims file contains conflicting information as to whether the Veteran has a current diagnosis of diabetes. The Veteran has submitted private treatment records from February 2007 including a metabolic panel showing a high glucose reading and impaired glucose level if fasting. In contrast, VA medical records list no diabetes. VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low for the purposes of obtaining a medical opinion. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83. As medical record leave a question as to whether the Veteran has a current disability, the issue is remanded in order for the Veteran to be afforded a VA examination to clarify whether he has diabetes. See McLendon, 20 Vet. App. at 79. 2. Entitlement to service connection for hypertension, including as due to herbicide exposure, to include as secondary to PTSD and diabetes The Veteran contends that he suffers from hypertension as a result of his acknowledged exposure to herbicide agents while serving in the Republic of Vietnam. In the alternative, he contends that his hypertension is secondary to his PTSD and diabetes. The Veteran was provided with a VA hypertension examination in March 2018 where the examiner opined that the Veteran's hypertension was less likely than not secondary to his PTSD. The examiner noted that although "hypertension has been associated with patients who have PTSD however no direct causal link has been established." However, this medical opinion does not include a discussion regarding aggravation of the Veteran's hypertension by his service-connected PTSD. An opinion regarding secondary service connection is inadequate if it does not address both causation and aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136, 138 (2013). As such, the issue must be remanded for an addendum medical opinion that addresses aggravation. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (holding that once VA has provided a VA examination or obtained a medical opinion, it is required to provide or obtain one that is adequate for the purpose sought). Additionally, the Board notes that in January 2019, the Veteran submitted an article indicating that "there is a bidirectional causal relationship between PTSD and inflammation." Upon remand, the addendum medical opinion should consider and address this article. Further, the Veteran submitted an article in February 2018 indicating that "occupational herbicide exposure history and Vietnam-service-status were significantly associated with hypertension risk." In December 2020, the Veteran submitted a deposition where he cited to a National Academies of Sciences, Engineering and Medicine (NAS) study which found sufficient evidence of an association for hypertension and monoclonal gammopathy of undetermined significance (MGUS) and exposure to Agent Orange and other herbicides used during the Vietnam War. The Board notes that 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. The Board cannot make a fully informed decision on the issue of entitlement to service connection for hypertension because no VA examiner has opined whether the Veteran's hypertension is related to his herbicide exposure while in service. As such, on remand, an examiner should provide a medical opinion on the relationship between the Veteran's hypertension and herbicide exposure. 3. Entitlement to service connection for aortic aneurysm, including as due to herbicide exposure, to include as secondary to PTSD, hypertension, and diabetes The Veteran contends that he suffers from an aortic aneurysm as a result of lifting weights in service or due to his acknowledged exposure to herbicide agents while serving in the Republic of Vietnam. In the alternative, he contends that his aortic aneurysm is secondary to his PTSD, hypertension, and diabetes. The evidence of record includes an October 2014 examination listing an aortic aneurysm as an active problem. In February 2018, the Veteran submitted an article suggesting that PTSD "is associated with major forms of cardiovascular disease." The Board cannot make a fully informed decision on the issue of entitlement to service connection for an aortic aneurysm because no VA examiner has opined whether the Veteran's aortic aneurysm is related to his service or is secondary to his PTSD. On remand, a medical opinion should be obtained to determine the nature and etiology of any heart disability. See McLendon, 20 Vet. App. at 79. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician for his claimed diabetes. The claims file should be made available for review. The examiner should perform any testing necessary to determine whether the Veteran has type II diabetes mellitus or any other type of diabetes diagnosis. A fully articulated medical rationale for any opinion expressed must be set forth in the medical report. The examiner should discuss the particulars of this Veteran's medical history and the relevant medical science as applicable to this case, which may reasonably explain the medical guidance in the study of this case. 2. Obtain an addendum opinion from an appropriate clinician to determine the nature and etiology of the Veteran's hypertension. The need for a physical examination is left to the discretion of the medical professional offering the medical opinion. The claims file should be made available for review. The examiner should provide opinions on the following: a) Is it at least as likely as not that the Veteran's hypertension is related to his service, to include acknowledged exposure to herbicides? In so opining, the examiner must consider and discuss the following: i) the article submitted in February 2018 indicating that "occupational herbicide exposure history and Vietnam-service-status were significantly associated with hypertension risk," and ii) the Veterans and Agent Orange: Update 11 (2018) by the National Academies of Sciences, Engineering and Medicine (NAS) indicating that there is sufficient evidence of an association between hypertension and herbicide exposure. In providing the opinion, the examiner must take into account the Veteran's personal circumstances and how the recognized risk factor(s) apply in his particular case. The examiner may not rely solely on the fact that the Veteran's hypertension is not on the presumptive list of diseases associated with herbicide exposure. b) Is it at least as likely as not that the Veteran's hypertension was (A) caused or (B) aggravated beyond its normal progression by his service-connected PTSD? In so opining, the examiner should consider and discuss the article submitted in January 2019 indicating that "there is a bidirectional causal relationship between PTSD and inflammation." c) If the Veteran has a diagnosis for diabetes, is it at least as likely as not that the Veteran's hypertension was (A) caused or (B) aggravated beyond its normal progression by his diabetes? Aggravation means an increase in disability any additional impairment of earning capacity of the nonservice-connected disability. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the diagnosed disability prior to aggravation by the service-connected disability. A fully articulated medical rationale for any opinion expressed must be set forth in the medical report. The examiner should discuss the particulars of this Veteran's medical history and the relevant medical science as applicable to this case, which may reasonably explain the medical guidance in the study of this case. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any heart disability, to include aortic aneurysm. The claims file should be made available for review. The examiner should provide opinions on the following: a) Identify all current heart diagnoses. b) Is it at least as likely as not that the Veteran's heart disability is related to his service, to include acknowledged exposure to herbicides? In providing the opinion, the examiner must take into account the Veteran's personal circumstances and how the recognized risk factor(s) apply in his particular case. The examiner may not rely solely on the fact that certain heart disabilities, such as aortic aneurysm, are not on the presumptive list of diseases associated with herbicide exposure. c) Is it at least as likely as not that the Veteran's heart disability was (A) caused or (B) aggravated beyond its normal progression by his service-connected PTSD? In so opining, the examiner must consider and discuss the article submitted in February 2018, suggesting that PTSD "is associated with major forms of cardiovascular disease." c) Is it at least as likely as not that the Veteran's heart disability was (A) caused or (B) aggravated beyond its normal progression by his hypertension? d) If the Veteran has a diagnosis for diabetes, is it at least as likely as not that the Veteran's heart disability was (A) caused or (B) aggravated beyond its normal progression by his diabetes? Aggravation means an increase in disability any additional impairment of earning capacity of the nonservice-connected disability. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the diagnosed disability prior to aggravation by the service-connected disability. A fully articulated medical rationale for any opinion expressed must be set forth in the medical report. The examiner should discuss the particulars of this Veteran's medical history and the relevant medical science as applicable to this case, which may reasonably explain the medical guidance in the study of this case. Amanda Baker Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Morrad, 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.