Citation Nr: 21029877 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 18-46 234A DATE: May 17, 2021 REMANDED Entitlement to service connection for hypertension, to include as due to herbicide exposure and/or as secondary to service-connected disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1952 to July 1956 and from October 1956 to August 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2018 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran died in September 2018. The appellant is the Veteran's surviving spouse. In January 2020, the RO recognized the appellant as an eligible substitute claimant in the appeal. See 38 U.S.C. § 5121A This matter was remanded by the Board multiple times, most recently in November 2020. As discussed below, unfortunately another remand is necessary. Entitlement to service connection for hypertension, to include as due to herbicide exposure and/or as secondary to service-connected disability, is remanded. The Board remanded the Veteran's claim in November 2020 to, in part, obtain a VA medical opinion concerning the nature and etiology of his hypertension. In particular, the Board found the August 2020 VA examination inadequate, as the examiner seemed to indicate that the Veteran's exposure to Agent Orange in service may have at least in part caused the Veteran's hypertension. The Board noted that VA laws and regulations do not require that the injury or event in service is the sole cause of the current disability in order for the disability to be service connected. See November 2020 Board Remand. The Board directed the examiner to offer an addendum opinion, requesting the examiner opine on "Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's hypertension is at least in part related to or caused by active service to include any documented high blood pressure readings in service and/or exposure to herbicides to include Agent Orange during active service." See id. The RO obtained an addendum opinion in December 2020, where the examiner did not discuss or opine on the Veteran's herbicide exposure at all, and instead stated "As per Agent Orange opinion-please refer to C & P examination dated 05 Aug 2020 where this point is discussed." See December 2020 VA Examination. The Board finds the December 2020 VA medical opinion inadequate, as it is not responsive to the directives posed by the Board in the November 2020 remand. Indeed, the November 2020 remand found the August 2020 VA examination inadequate, and specifically asked the examiner to opine on whether the Veteran's hypertension is at least in part related to or caused by active service to include any documented high blood pressure readings in service and/or exposure to herbicides to include Agent Orange during active service. Based on the above, the Board finds that the medical opinion did not substantially comply with the November 2020 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998) (a remand confers upon the claimant, as a matter of law, the right to compliance with the remand directives); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (noting that Stegall requires substantial compliance with remand orders, rather than absolute compliance). Therefore, the Board finds that a new VA medical opinion is necessary to fully address the nature and etiology of the Veteran's claim for service connection. The matters are REMANDED for the following action: 1. Return the claims file to the December 2020 VA examiner for an addendum medical opinion. The claims file, including a copy of this remand, must be made available to the examiner for review, and the examiner should indicate that the claims folder was reviewed in connection with providing the medical opinion. The examiner is requested to review all pertinent records associated with the claims file and offer an opinion as to the following: (a) Whether the Veteran's hypertension was at least as likely as not (50% or greater probability) caused by his in-service exposure to herbicide agents? In addressing the above, the examiner must consider and address the NAS, Veterans and Agent Orange: Update 11 (2018), which reflects that NAS upgraded hypertension to the "sufficient" category from "limited or suggestive," indicating that "there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and an herbicide agent. See http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=25137. The examiner should determine in this specific case, whether the Veteran's hypertension was related to his Agent Orange exposure. The examiner must take into account the Veteran's personal circumstances and how the recognized risk factor(s) apply in his particular case. Other factors may affect the analysis, such as whether the examiner finds studies persuasive, whether there are other risk factors that might have been the cause of the Veteran's hypertension, whether his hypertension manifested itself in an unusual manner, etc. The examiner is reminded that that VA laws and regulations do not require that the injury or event in service is the sole cause of the current disability in order for the disability to be service connected. (b) Whether the Veteran's hypertension was at least as likely as not (50% or greater probability) (i) caused by, OR (ii) aggravated by (worsened beyond the natural progression) his service-connected diabetes mellitus. In addressing the above, the examiner must review and consider the medical articles referenced in the May 2021 Appellate Brief. See (Adam: Grainger & Allison's Diagnostic Radiology, 5th edition. http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-0-443-10163-2...50025-7&ISBN=978-0-443-10163-2&Sid=1513809510&uniqId=441648281-15#4-u1.0-B978-0-443-10163-2...50025-7--cesec43); and (Johan Ärnlöv, MD, PhD; Michael J. Pencina, PhD; Byung-Ho Nam, PhD; James B. Meigs, MD; Caroline S. Fox, MD, MPH; Daniel Levy, MD; Ralph B. D'Agostino, MD; Ramachandran S. Vasan, MD. Relations of Insulin Sensitivity to Longitudinal Blood Pressure Tracking Variations with Baseline Age, Body Mass Index, and Blood Pressure. Circulation. 2005; 112:1719-1727; originally published online September 12, 2005). A complete, clearly-stated explanation for the conclusions reached-to include identification of evidence and medical authority relied upon-must be provided. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Mohammad 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.