Citation Nr: 21030115 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 18-28 357 DATE: May 17, 2021 ORDER Entitlement to a disability rating of 70 percent, but no higher, for posttraumatic stress disorder (PTSD, claimed as depression and anxiety) is granted. Entitlement to service connection for bilateral upper extremity peripheral neuropathy is granted. Entitlement to service connection for hypertension is granted. REMANDED Entitlement to service connection for hepatitis C (also claimed as liver disease) is remanded. Entitlement to SMC based on Aid and Attendance/housebound is remanded. FINDINGS OF FACT 1. During the relevant appeal period, the Veteran's PTSD symptoms have not manifested in symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of personal hygiene), disorientation to time and place, or memory loss for names of close relatives, own occupation, or own name. 2. Resolving reasonable doubt in the Veteran's favor, there is a diagnosis of bilateral upper extremity peripheral neuropathy related to the service-connected diagnosis of diabetes mellitus type II. 3. The Veteran is currently diagnosed with hypertension. 4. Epidemiologic evidence concludes that there is "sufficient" evidence of an association between hypertension and herbicide exposure. 5. The evidence is at least in equipoise as to whether the Veteran's currently diagnosed hypertension is related to his exposure to herbicide agents during service. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Veteran, the criteria for entitlement to a disability rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. § 4.126, 4.3, 4.7, 4.130, Diagnostic Code 9411. 2. The criteria for entitlement to service connection for bilateral upper extremity peripheral neuropathy have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from October 1966 to October 1968. In September 2019, the Board denied entitlement to a rating in excess of 50 percent for PTSD. The Board remanded the remaining claims on appeal. The Veteran appealed the denial for an increased rating for PTSD to the U.S. Court of Appeals for Veterans Claims (Court). Pursuant to a July 2020 Joint Motion for Partial Remand (JMPR) between the Secretary of Veterans Affairs (Secretary) and counsel for the Veteran, the Court vacated the portion of the September 2019 Board's decision that denied a disability rating in excess of 50 percent for PTSD. The claims have been returned to the Board for further consideration. Increased Rating Claim PTSD The Veteran submitted a claim for anxiety and depression in November 2015. As the AOJ had already granted entitlement to service connection for PTSD, this claim was processed as a claim for increased disability rating for PTSD. In a September 2019 decision, the Board affirmed the prior AOJ rating decision to continue the disability rating at 50 percent for the Veteran's PTSD. The Veteran appealed this decision to the Court of Appeals for Veterans Claims (Court) and in an August 2020 decision, the Court returned a Joint Motion for Remand to the Board that vacated the prior Board decision denying an increase in excess of 50 percent for the Veteran's PTSD. The Court remanded for a decision with adequate rationale for a determination on the disability evaluation level for the Veteran's PTSD. In the decision herein, the Board finds that, based on resolving reasonable doubt in favor of the Veteran, a 70 percent disability rating, but no higher is warranted for the Veteran's PTSD. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings are sufficiently characteristic to identify the disease and the resulting disability and coordination of rating with impairment of function. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Mental disorders are evaluated under the general rating formula for mental disorders, a specific rating formula presented under 38 C.F.R. § 4.130. In addition, the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) provides guidance for the nomenclature employed within 38 C.F.R. § 4.130. However, effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the DSM-IV and replace them with references to the recently updated Diagnostic and Statistical Manual (Fifth Edition) (the DSM-5). See 79 Fed. Reg. 45,094 (August 4, 2014). VA adopted as final, without change, this interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board on or before August 4, 2014. See Schedule for Rating Disabilities - Mental Disorders and Definition of Psychosis for Certain VA Purposes, 80 Fed. Reg. 14,308 (March 19, 2015). In the present case, the RO certified the Veteran's appeal to the Board after August 4, 2014. Thus, the version of 38 C.F.R. § 4.125 conforming to the DSM-5 is applicable in the present case. In any event, the Board will still consider any private or VA examiner's discussion of both the DSM-IV and DSM-5 in adjudicating the current Veteran's PTSD claim, in order to provide the Veteran with every benefit of the doubt. When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). As provided by the General Rating Formula, 30 percent rating is authorized for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. A 50 percent disability rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is in order when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. A 100 percent rating is in order when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. A veteran need not exhibit "all, most, or even some" of the symptoms enumerated in the General Rating Formula for Mental Disorders to warrant the assignment of a higher rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Rather, the use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. Id. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. Mauerhan, 16 Vet. App. at 442. The Federal Circuit has clarified that the General Rating Formula for Mental Disorders requires not only (1) sufficient symptoms of the kind listed in the percentage requirements, or others of similar severity, frequency, or duration, but also (2) that those symptoms cause the level of occupational and social impairment specified in the regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). The Federal Circuit endorsed an approach whereby the Board would identify the symptoms associated with the service-connected mental health disability, determine whether they are of the kind enumerated in the regulation, and if so, assess whether they result in the level of occupational and social impairment specified by a particular rating. Id. In a November 5, 2015 CAPRI note, the medical provider reported that the Veteran was sustainable for outpatient care and expressed no suicidal or homicidal ideations. In a January 2016 letter, the Veteran's treating psychologist for five years explains that the Veteran is capable of managing his finances, describing "a level of financial acumen that far exceeds the minimum standard of competency." In a February 2016 VA PTSD examination, the examiner confirmed a diagnosis of PTSD and traits of antisocial personality disorder, stating that there are overlapping symptoms for the two such as irritability and impulsivity and it is not possible to differentiate between them. The examiner selected the box pertaining to the overall 50 percent level for PTSD. The Veteran denied intent to kill himself or to obtain drugs. The Veteran denied a plan to kills others but expressed he would defend himself if needed. The Veteran stated that he owns a gun, but his brother had possession of it because of concerns of the Veteran's irritability and anger. Regarding symptoms of PTSD, the examiner noted: difficulty in adapting to stressful circumstances including work or worklike setting; difficulty in establishing and maintaining effective work and social relationships; disturbances in motivation and mood; mild memory loss; depressed mood; suspiciousness; chronic sleep impairment. The examiner noted that the Veteran was clean and adequately groomed. The Veteran became visibly angry when discussing Vietnam. The examiner considered the Veteran to have clean, logical, and well-organized thoughts. The examiner noted that the Veteran denied suicidal or homicidal ideation. In August 2016, the Veteran presented at Detroit VA facility and CAPRI notes reflect that he had a positive mood with appropriate behavior. The Veteran was oriented with fair grooming and hygiene. The Veteran had goal-directed thoughts. According to the notes, the Veteran had come from St. Louis where he normally had been residing to "check things out" like housing. In a December 2016 statement, the Veteran expressed that holding jobs was difficult due to PTSD and being around people was stressful. At the March 2017 VA PTSD examination, the Veteran described himself as "not sociable." The Veteran reported that his son lived with him and that while they do talk about things like VA appointments, they generally stay in their own rooms. He explained that he does not like loud noises. The Veteran described that he lived in a senior community that regularly organizes social activities, but he did not participate, preferring to stay in his room. The Veteran described a "fear [he] might snap," explained as that he might become angry in social situations. The Veteran stated that he last worked in 2005 and had gotten into fights with coworker leading to termination. The Veteran recounted how he almost stabbed a coworker in the 1960s and had grabbed his granddaughter by the throat a couple years earlier after she set off a firecracker. The Veteran avoids crowds and movies about Vietnam. He stated he has symptoms like irritability, anger outburst, and sleep problems. The Veteran stated he carries a knife when he goes out. The Veteran denied suicidal and homicidal ideations relaying that he loves his son and would not want to leave him. The Veteran was attending PTSD therapy. Regarding symptoms of PTSD, the examiner noted: difficulty in adapting to stressful circumstances including work or worklike setting; difficulty in establishing and maintaining effective work and social relationships; disturbances in motivation and mood; mild memory loss; anxiety; suspiciousness; chronic sleep impairment. In a February 2018 letter, one of the Veteran's treating clinicians described that the Veteran had been working on his PTSD for several years and had maintained abstinence from drug use and alcohol for a decade. The letter describes that the Veteran has documented PTSD symptoms that include anger, irritability, sleep disturbance, concentration problems, avoidance, self-destructive behavior, and intrusive re-experiencing. The purpose of the letter was to support the Veteran in seeking TDIU and the letter describes how the Veteran is unemployable due to PTSD. In a March 2017 statement, the Veteran wrote, "I'm not going to kill myself or anybody else." The Veteran described being angry, frustrated and depressed. He lived with his son and the two didn't speak much. The Veteran also described bad dreams and sleep issues. In a separate March 2017 letter, the Veteran wrote that with reference to his PTSD, loud noises upset him as do unexpected movements. He stated that he does not like being around lots of people, he is anxious and irritable and has trust issues. In a July 16, 2020 telephone mental health appointment, the Veteran denied suicidal or homicidal ideations. In an August 2020 medical visit, the Veteran had a negative suicide screening. The Veteran's history shows that medical providers and the Veteran himself have described symptoms of PTSD that fall into a range between the 30 percent or 50 percent or 70 percent rating levels. If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. The Board finds that reasonable doubt exists between assigning a 50 percent or 70 percent disability evaluation level to the Veteran's PTSD, accordingly, a 70 percent rating should be assigned. In adjudicating this claim, the competence and credibility of lay statements must be considered by the Board. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Veteran contends that his PSTD symptoms warrant a higher rating. The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences. Layno v. Brown, 6 Vet. App. 465 (1994). The Board finds that the Veteran's statements about his PTSD symptoms are credible where they are consistent with the overall record. The Veteran's overall record does not demonstrate that his PTSD symptoms manifest in gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of personal hygiene), disorientation to time and place, or memory loss for names of close relatives, own occupation, or own name. Accordingly, the Veteran's PTSD does not most nearly approximate the 100 percent disability level. The appeal for an increased rating for PTSD is granted at a level of 70 percent, but no higher. 38 C.F.R. § 4.7. Service Connection A veteran is entitled to VA disability compensation if there is disability resulting from personal injury suffered or disease contracted in line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active service. 38 U.S.C. § 1110. Generally, to establish a right to compensation for a present disability, a veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303 (a). Lay evidence can be competent and sufficient to establish the elements of service connection when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In short, when considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent on the issues of diagnosis and medical causation. Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). For instance, a layperson is competent to identify such disorders as varicose veins, tinnitus, and flat feet. 38 C.F.R. § 3.159 (a)(2); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); Charles v. Principi, 16 Vet. App. 370, 374 (2002); Falzone v. Brown, 8 Vet. App. 398, 405 (1995). In contrast, a layperson is not competent to identify medical conditions that require scientific, technical, or other specialized knowledge, such as in identifying bronchial asthma. 38 C.F.R. § 3.159(a)(1); Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board must assess the competence and credibility of lay statements. Barr, 21 Vet. App. at 308. The Federal Circuit has held that the Board can favor competent medical evidence over lay statements offered by the Veteran, as long as the Board neither deems lay evidence categorically incompetent nor improperly requires a medical opinion as the sole way to prove causation. King v. Shinseki, 700 F.3d 1339, 1344 (2012). Service connection may be granted for a disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303 (d). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Service connection may also be established by the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In determining whether service connection is warranted, the Board shall consider the benefit-of-the-doubt doctrine. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518 (1996); Gilbert v. Derwinski, 1 Vet. App. 49 (1991). Bilateral upper extremity peripheral neuropathy The Veteran contends that he developed bilateral upper extremity peripheral neuropathy as a result of service-connected diabetes mellitus. After a thorough review of the evidence and resolving reasonable doubt in favor of the Veteran, the Board finds the issue of whether the Veteran has a diagnosis of bilateral upper extremity peripheral neuropathy as well as the relationship of the diagnosis to diabetes mellitus to be in equipoise, accordingly, entitlement to service connection for bilateral upper extremity peripheral neuropathy is warranted. As background, the AOJ granted entitlement to service connection for diabetes mellitus type II with an effective date of October 2006. The AOJ later severed service connection for diabetes effective April 2008, stating that the Veteran's records did not confirm a diagnosis. The Veteran submitted a new claim and currently the Veteran has entitlement to service connection for diabetes mellitus type II with an effective date of February 23, 2010. This entitlement is relevant because according to the Veteran's medical records, he has been diagnosed with both idiopathic peripheral neuropathy, and diabetic peripheral neuropathy, and peripheral vascular disorder, all of which can have overlapping symptoms. The Veteran also currently has entitlement to service connection for peripheral neuropathy of the bilateral lower extremities with an effective date of February 23, 2010. In February 2014 VA examinations for diabetes and peripheral neuropathy, the examiner diagnosed diabetes mellitus type II and diabetic peripheral neuropathy. The examiner marked symptoms attributed to both upper and lower extremity diabetic peripheral neuropathy such as paresthesias and numbness. However, the examiner responded in the negative to the section asking, "does the veteran have upper extremity peripheral neuropathy?" In the March 2016 VA examination for diabetic peripheral neuropathy, the examiner marked symptoms attributed to both upper and lower extremity diabetic peripheral neuropathy such as moderate constant pain, severe intermittent pain, severe paresthesias, and severe numbness. However, the examiner responded in the negative to the section asking, "does the veteran have upper extremity peripheral neuropathy?" In the March 2016 VA examination for diabetes, the examiner responded affirmatively to the question asking about complications related to diabetes as including diabetic peripheral neuropathy. In the associated medical opinion, the examiner stated that, generally, "early impairment of glucose, classified as pre-diabetes is associated with neuropathy." The examiner then explained that, generally, there is medical history that diabetic neuropathy begins in the lower extremities and then progresses to the upper extremities. According to the examiner, the Veteran in this case had diabetes under control and accordingly, the blood glucose levels not lending to progression to bilateral upper extremity peripheral neuropathy. The examiner mentions that the Veteran also has a vascular disease and that for the lower extremities, the examiner is unable to separate symptoms of numbness, burning, tingling as due to vascular disease or due to idiopathic or diabetic neuropathy. In the March 2017 VA examination for diabetic peripheral neuropathy, the examiner marked symptoms attributed to both upper and lower extremity diabetic peripheral neuropathy such as constant pain, intermittent pain, paresthesias, and numbness. However, the examiner responded in the negative to the section asking, "does the veteran have upper extremity peripheral neuropathy?" The examiner noted that the Veteran reported tingling, numbness and pain of the upper and lower extremities. The examiner noted that the Veteran has diabetic peripheral neuropathy. The associated April 2018 opinion was later deemed inadequate in the September 2019 Board decision. The AOJ obtained another medical opinion in December 2019 wherein the examiner opined that the Veteran's idiopathic peripheral neuropathy was not as least as likely as not related to active service. The examiner stated that the Veteran's upper and lower extremity peripheral neuropathy is not as least as likely as not related to the service-connected diabetes. The examiner noted that the Veteran also has idiopathic peripheral neuropathy and a vascular condition with statis dermatitis in the lower extremities which can cause peripheral neuropathy. The examiner noted that the Veteran's current diabetic level is more likely as pre-diabetes based on lab work. The examiner opined that the Veteran's prediabetes that is well-controlled is not as least as likely as not contributing to the Veteran's neuropathy, which is listed in medical records as idiopathic neuropathy. In the associated examination report, the examiner recorded that the Veteran did not have and never had a diagnosis of diabetic peripheral neuropathy. The examiner reported that there were no symptoms attributable to diabetic peripheral neuropathy in either the upper or lower extremities. The examiner stated that the Veteran's medical records reflect idiopathic peripheral neuropathy and that diabetic peripheral neuropathy was a misdiagnosis. In a July 2017 statement, the Veteran wrote that he has pain, numbness and tingling in his hands, feet, and legs. In a July 5, 2020 CAPRI note, the medical provider recorded that the Veteran's diabetes has always been "mild" and accordingly, peripheral neuropathy has an "unclear etiology." In the March 2016 opinion, the examiner stated that, generally, "early impairment of glucose, classified as pre-diabetes is associated with neuropathy." Another examiner in December 2019 opined that the Veteran had no diagnosis of diabetic peripheral neuropathy in either upper or lower extremities (despite already having entitlement to service connection for lower extremity diabetic peripheral neuropathy) and that the previous findings of such were a misdiagnosis. The same examiner noted that the Veteran likely has prediabetes, although service-connected for diabetes mellitus type II. A July 2020 medical provider stated that the etiology of peripheral neuropathy was "unclear." Regarding the Veteran's lower extremity peripheral neuropathy, the examiner in December 2019 opined that it was also idiopathic, whereas another examiner opined that it could be attributable to diabetic peripheral neuropathy or idiopathic. In summary, the weight of the evidence is at least in equipoise as to a finding that the Veteran's has a current diagnosis of bilateral upper extremity peripheral neuropathy as well as to whether the etiology is secondary to service-connected diabetes mellitus type II, which may or may not still be in the prediabetes stage. As a result, service connection is warranted based on resolving reasonable doubt in favor of the Veteran where the evidence is in approximate balance for the claim for bilateral upper extremity diabetic peripheral neuropathy. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Hypertension The Agency of Original Jurisdiction (AOJ) previously determined that the Veteran was exposed to Agent Orange as a result of his Vietnam service. The Veteran has been diagnosed with hypertension. See e. g., December 2019 VA hypertension examination report. VA regulations do not provide hypertension as a presumptive disability associated with herbicide exposure. However, the National Academy of Sciences (NAS) in 2006 and 2008 updates, concluded that there was "limited or suggestive evidence of an association" between hypertension and herbicide exposure. See 75 Fed. Reg. 32,540, 32,549 (June 8, 2010); 75 Fed. Reg. 81,332, 81,333 (December 27, 2010). In a 2018 update, the NAS found that there was "sufficient" evidence of an association between hypertension and exposure to herbicides used during the Vietnam War. Notably, a VA medical opinion dated in December 2019 provided a negative nexus opinion, but did not address the NAS 2018 update. Therefore, and according to the NAS, the sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association between hypertension and herbicide exposure. Resolving reasonable doubt in the Veteran's favor, service connection for hypertension is warranted. REASONS FOR REMAND hepatitis C (also claimed as liver disease) The Veteran contends that his hepatitis C is likely due to intravenous drug usage as a result of self-medicating for his PTSD symptoms. The Board remanded this issue in a September 2019 decision for a new opinion that considered whether the Veteran's PTSD caused the Veteran's drug use. As written in the September 2019 Board opinion, "The Board notes that for claims filed after October 31, 1990, service connection on a direct incurrence basis cannot be granted for disabilities resulting from abuse of alcohol or drugs. See 38U.S.C. §§105, 1110; 38C.F.R. §§3.1(n), 3.301. Further, compensation cannot be awarded pursuant to 38U.S.C. §1110 and 38C.F.R. §105(a) either for a primary alcohol/drug abuse disability incurred during service or for any secondary disability that resulted from primary alcohol/drug abuse during service. Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). However, service connection for compensation may be established for an alcohol/drug abuse disability acquired as secondary to, or as a symptom of, a service-connected disability. In addition, veterans may recover only if they can adequately establish that their alcohol or drug abuse disability is secondary to or is caused by their primary service-connected disorder. Id. at 1381." The Board directed the AOJ to obtain a medical opinion that answered the question of whether the Veteran's drug use was caused or aggravated by the Veteran's PTSD, with a sufficient rationale to explain the opinion. In a December 2019 VA opinion, the examiner opined that the Veteran's Hepatitis C was due to "poor judgment and drug behavior that led the Veteran to use dirty needles" and "there is no available medical literature to link biological diseases (viral in this case) to psychiatric diagnoses." The examiner then states about herself, "This examiner is not a psychiatrist." As this opinion does not offer an adequate rationale about whether PTSD could have influenced the Veteran to abuse illegal drugs thus acquiring Hepatitis C, the Board must remand for a new opinion. The AOJ is requested to find a psychiatrist to make this opinion. SMC based on Aid and Attendance/housebound Finally, because a decision on the remanded issue of Hepatitis C could significantly impact a decision on the issue of SMC based on Aid and Attendance, the issues are inextricably intertwined. A remand of the claims for SMC for Aid and Attendance is required. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from a VA Psychiatrist about the Veteran's drug use as it relates to PTSD as a cause of Hepatitis C. The examiner is asked to respond to the following: (a.) Opine as to whether it is it at least as likely as not (i.e. probability of 50 percent or greater) that the Veteran's service-connected PTSD either (1) caused or (2) aggravated the Veteran's drug use. **Please note that for secondary service connection, "aggravation" need not be permanent in nature. See Ward v. Wilkie, 31 Vet. App. 233, 241-42 (2019). (b.) The examiner should offer appropriate supporting rationale based on the Veteran's medical history, mental health history and treatment for PTSD, his lay statements and any relevant medical literature or principles. 2. If service connection for Hepatitis C is granted, schedule the Veteran for an appropriate VA examination to determine the need for SMC based on aid and attendance due to the Veteran's service-connected disabilities. 3. After completing the above development readjudicate the claims on appeal. Romina A. Casadei Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Miller, 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.