Citation Nr: 21030264 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 17-62 852 DATE: May 18, 2021 REMANDED Entitlement to service connection for residuals of a left femur fracture is remanded. Entitlement to service connection for a left knee disability, to include as secondary to residuals of a left femur fracture, is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1965 to January 1987, including service in the Republic of Vietnam. This case was most recently before the Board in June 2019 when it was remanded for additional development. There has not been substantial compliance with the Board's previous remand directives. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for residuals of a left femur fracture is remanded. 2. Entitlement to service connection for a left knee disability is remanded. The Veteran alleges that he fractured his left femur during service and that he currently experiences residuals of that fracture. Review of the claims file reflected that some of the Veteran's service treatment records have not been obtained, particularly those prior to 1979. The available service treatment records document the Veteran's reports of fracturing his left femur in 1972 or 1973, but do not confirm the in-service injury. A September 2013 VA treatment record notes the Veteran's reports that after fracturing his left femur he spent eight weeks in a hospital in traction. June 2012 private medical records also indicate his knee problems may be related to a femur fracture that occurred sometime in the 1970s. The June 2019 Board remand instructed the Agency of Original Jurisdiction (AOJ) to request the Veteran to identify the name and location of the hospital where he was treated for his in-service left femur fracture and attempt to obtain those records from National Personnel Records Center (NPRC). In July 2019, the AOJ requested that information from the Veteran. In response, the Veteran indicated that he was treated at Kadena Air Force Base in Okinawa, Japan, in 1974. A January 2020 VA correspondence indicates that the AOJ contacted NPRC, but no relevant records were located. On remand, the AOJ should obtain a complete copy of the Veteran's military personnel and treatment records to ensure that all relevant service records are in the claims file. Additionally, no VA examiner has opined as to the nature and etiology of any residuals of a left femur fracture. On remand, the AOJ should obtain a relevant VA examination. As the medical evidence suggests that the Veteran's left knee disability may be related to the in-service left femur fracture, the Veteran's claim for entitlement to service connection for a left knee disability is inextricably intertwined with the claim for entitlement to service connection for residuals of a left femur fracture. Harris v. Derwinski, 1 Vet. App. 180 (1991). 3. Entitlement to service connection for hypertension is remanded. A January 2020 VA examiner opined that the Veteran's current diagnosis of hypertension is not etiologically related to sporadic elevated blood pressure readings during service but is etiologically related to his presumed exposure to herbicides. However, the examiner did not provide any rationale for the determination that the Veteran's hypertension is related to herbicide exposure. By contrast, a July 2020 opinion from a different VA examiner determined that the Veteran's hypertension is not related to herbicide exposure, opining that hypertension is not considered a presumptive condition related to herbicide exposure. The examiner further opined that medical literature and medical evidence did not support a nexus between hypertension and herbicide exposure. The Board notes, however, that Veterans and Agent Orange: Update 11 (2018) moved hypertension from the "limited or suggestive" category to the category of "sufficient" evidence of an association with herbicide exposure. A remand is needed to obtain an additional VA opinion that discusses this update and reconciles the two contrasting opinions of record. 4. Entitlement to a TDIU rating is remanded. Because decisions on all of the remanded issues could significantly impact a decision regarding entitlement to a TDIU rating, the issues are inextricably intertwined. A remand of the claim for entitlement to a TDIU rating is required. Issues are considered to be inextricably intertwined when a determination on one issue could have a significant impact on the outcome of another. Harris, supra. The matters are REMANDED for the following action: 1. Obtain any available VA treatment records since September 2017 and associate them with the claims file. 2. Contact the National Personnel Records Center and obtain a complete copy of the Veteran's active service military personnel records. All attempts to obtain records should be documented in the claims folder. 3. Schedule the Veteran for an examination by an appropriate examiner for an opinion regarding the nature and etiology of any residuals of a left femur fracture and any diagnosed left knee disorder. The examiner should answer the following questions: (a) Is it at least as likely as not (50 percent or greater possibility) that any residuals of a left femur fracture are etiologically related to military service? The examiner should discuss whether there is any medical reason to accept or reject the Veteran's contention that he fractured his left femur in a motor vehicle accident during service in the 1970s. (b) Is it at least as likely as not (50 percent or greater possibility) that any left knee disorder is etiologically related to military service? (b) Is it at least as likely as not (i.e., probability of 50 percent or greater) that any residuals of a left femur fracture caused or aggravated (a medically discernible increase in functional impairment e.g. increase in the severity, frequency or duration of symptoms or additional functional impairment beyond the expected baseline impairment) any diagnosed left knee disorder? In answering these questions, the examiner should address the following: September 2013 VA treatment record noting the Veteran's reports that, after fracturing his left femur, he spent eight weeks in a hospital in traction; November 2012 and March 2012 private medical records containing imaging reflecting an old healed fracture of the distal left femoral shaft; and June 2012 private medical records indicating the Veteran's knee problems may be related to a 1970s femur fracture. A complete rationale must be provided for the opinions offered. 4. Forward the Veteran's claims file to the January 2020 examiner or another appropriate examiner for an opinion addressing the nature and etiology of the Veteran's current diagnosis of hypertension. The examiner should note that the Veteran's in-service exposure to herbicides is conceded, and should answer the following question: Is it at least as likely as not (i.e., probability of 50 percent or greater) that any diagnosed hypertension began in service, was caused by service, or is otherwise etiologically related to active duty service, to include exposure to herbicides? In providing this opinion, the examiner should accomplish the following: discuss the significance of Veterans and Agent Orange: Update 11 (2018) which moved hypertension from the "limited or suggestive" category to the category of "sufficient" evidence of an association with herbicide exposure; and reconcile the conflicting January 2020 and July 2020 VA opinions regarding whether the Veteran's hypertension is etiologically related to his herbicide exposure. If an examination is needed, one should be scheduled. A complete rationale must be provided for the opinion. 5. After completing the actions detailed above, readjudicate the claims remaining on appeal, and adjudicate the claim for entitlement to a TDIU rating. If any additional examinations are needed to adjudicate the TDIU claim, those examinations should be scheduled. If any benefit is not granted to Veteran's satisfaction, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. J. Komperda Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Howell, 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.