Citation Nr: 21030872 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 12-26 882 DATE: May 19, 2021 REMANDED Entitlement to service connection for prostate cancer is remanded. Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1969 to November 1970. In October 2015, the case came before the Board. The Board remanded the issue of entitlement to service connection for prostate cancer in order to obtain the Veteran's private treatment records. Moreover, the Board wanted to determine whether the Veteran's private doctor's diagnosis of prostate cancer was based on diagnostic testing or a medical history provided by the Veteran. Furthermore, the Board remanded the Veteran's claim for entitlement to service connection for hypertension in order for a VA examiner to provide an addendum opinion as to whether the Veteran's service-connected diabetes aggravated his hypertension. In September 2019, the case returned to the Board. The Board denied entitlement to service connection for erectile dysfunction. The Board also remanded the Veteran's claim for entitlement to service connection for prostate cancer because the RO did not complete the tasks that the Board requested in the October 2015 remand. Moreover, the Board remanded the Veteran's claim for entitlement to service connection for hypertension because the May 2018 VA examiner did not adequately address aggravation or provide a complete rationale as to secondary service connection. The Board notes that the RO made several attempts to acquire the Veteran's private treatment records following the September 2019 Board Remand. The record reflects that the Veteran's doctor never responded to these requests. The record also reflects that the Veteran's private doctor did not respond to a telephone call from the RO. Therefore, the Board finds that the RO substantially complied with the Board's directive and that an additional remand to acquire this information is not necessary. 1. Entitlement to service connection for prostate cancer is remanded. As to the Veteran's claim for service connection for prostate cancer, the Board notes that the Veteran has not been afforded a VA examination for this disability. According to McLendon, an examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in- service event, injury, or disease," or that a disease, manifested in accordance with presumptive service connection regulations, occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the record reflects that the Veteran may have a diagnosis for prostate cancer. Moreover, the record reflects that the Veteran has served in the Republic of Vietnam and there is insufficient evidence to decide this case. As the Board finds that the criteria set forth in McLendon has been met to this claim, a VA examination should be obtained. 2. Entitlement to service connection for hypertension is remanded. In December 2020, an addendum opinion was obtained. The examiner simply stated that the Veteran's service-connected diabetes is not causing renal damage at this time. The Board notes that the Veteran attended a VA examination for this issue in March 2018. The Board finds that this opinion inadequate to decide this case because it is not a thorough and well-reasoned analysis of the secondary effects of the Veteran's diabetes upon his heart and hypertension. Thus, the Board finds that, a remand is required to obtain a more complete medical opinion as to the nature and etiology of the Veteran's disability. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.310; Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate); Bloom v. West, 13 Vet. App. 185, 187 (1999) (a medical opinion without supporting clinical data or other rationale does not provide the required degree of medical certainty). The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records from February 12, 2021, to the present. 2. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran's claimed prostate cancer. The electronic claims file must be reviewed by the examiner. All indicated testing and studies must be conducted, and all pertinent symptomatology must be reported in detail. (a) Please state whether the Veteran has a diagnosis of prostate cancer. (b) If the Veteran does not qualify for a diagnosis of prostate cancer, please explain why. (c) If the Veteran does not have prostate cancer but has another disability associated with the prostate, state whether it is at least as likely as not that such disability is related to service, to include the Veteran's in-service exposure to Agent Orange. 3. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran's hypertension. The electronic claims file must be reviewed by the examiner. All indicated testing and studies must be conducted, and all pertinent symptomatology must be reported in detail. (A). Is it at least as likely as not (50 percent probability or greater) that the Veteran's hypertension, had its onset in service or is caused by or related at least in part to his active service, to include his exposure to Agent Orange? (B). Is it as least as likely as not that the Veteran's hypertension was caused or aggravated by the Veteran's service-connected diabetes? The examiner's opinion should include a discussion regarding the National Academy of Sciences (NAS) Veterans and Agent Orange Update 2018, which moved hypertension from the "limited or suggestive evidence" category to the "sufficient evidence of an association" category. In providing the requested opinions, the examiners should consider the Veteran's competent lay claims regarding the observable symptoms he has experienced. The VA examination report must include a complete rationale for all opinions expressed. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Rescan, 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.