Citation Nr: 21032108 Decision Date: 05/25/21 Archive Date: 05/25/21 DOCKET NO. 16-46 705A DATE: May 25, 2021 REMANDED Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran had active military service in the United States Marine Corps from July 1971 to July 1975, to include service in the Republic of Vietnam. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2013 rating decision issued by the VA Regional Office (RO). In December 2018, the Board granted service connection for bilateral hearing loss and tinnitus and remanded the issue of entitlement to service connection for hypertension in order to obtain a new VA examination. 1. Entitlement to service connection for hypertension is remanded. Although regrettable, additional remand is required for full compliance with the Board's previous remand instructions. Stegall v. West, 11 Vet. App. 268, 270-71 (1998). The Veteran contends that his hypertension is related to his active service, due to exposure to herbicides, or, alternatively, secondary to his service-connected diabetes mellitus, type II. In its December 2018 Board remand, the Board noted that the Veteran served in Vietnam and as such exposure to herbicides is conceded. The Board stated that although hypertension is not listed as a disease associated with herbicide exposure under 38C.F.R.§3.309(e), the governing regulations do not preclude the Veteran from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (1994). Further, the Board noted that service treatment records (STRs) reflected that the Veteran had an elevated blood pressure reading upon enlistment in March 1971 and that the enlistment examination noted that the Veteran had high blood pressure, which was treated by a physician. The Board stated that additional elevated blood pressure readings were noted during service, and in June 1974, the Veteran's blood pressure was regularly monitored. The Board expressed that at the Veteran's June 1975 separation examination, the Veteran's blood pressure reading remained elevated. In addition, the Board noted that in March 2011 and June 2012, the Veteran was afforded VA examinations. The Board found that there was no evidence that the examiner reviewed the Veteran's STRs. The Board noted that the examiner opined that it is less likely than not that the Veteran's hypertension was secondary to his diabetes as the Veteran's treatment and diagnosis for hypertension preceded that for diabetes by at least twenty years. The examiner also expressed that there was no renal insufficiency from any cause to suggest an aggravating trigger of hypertension. The Board found that in light of the Veteran's treatment for high blood pressure prior to and during service, the post-service diagnosis of hypertension, and the inadequacy of the March 2011 and June 2012 VA examination reports; the Veteran should be afforded an additional VA examination. Additionally, the Board stated that the Veteran has asserted that his hypertension may be due to exposure to herbicides or secondarily-related his service-connected diabetes mellitus Type II. In accordance with the Board remand, the Veteran was afforded a VA examination in January 2020. The examiner opined that the Veteran's hypertension was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner stated that per his enlistment documentation, the Veteran's hypertension preceded his enlistment. The examiner opined that the Veteran's hypertension is less likely than not proximately due to or the result of the Veteran's service-connected diabetes. The examiner stated that the Veteran's hypertension diagnosis precedes his diabetes diagnosis by many years, so it is not secondary to diabetes. With respect to whether hypertension clearly and unmistakably existed prior to the Veteran's active service, the examiner stated that the Veteran's enlistment blood pressure was elevated and could be categorized as "Stage 1" 130-139 systolic, 80-89 diastolic. If the Veteran's hypertension was found to clearly and unmistakable exist prior to service, the examiner was asked to provide an opinion regarding whether the Veteran's hypertension was aggravated by service, to include as due to exposure to herbicides. The examiner stated that hypertension is not a presumed herbicide exposure condition. With respect to whether the Veteran's hypertension was at least as likely as not chronically worsened by the Veteran's service-connected diabetes mellitus, the examiner stated that the Veteran's hypertension diagnosis precedes his diabetes diagnosis by many years so it is not secondary to this condition. The Veteran was afforded an addendum opinion in September 2020. The examiner opined that the Veteran's hypertension is less likely than not proximately due to or the result of the Veteran's service-connected diabetes. The examiner stated that the Veteran's hypertension existed prior to enlistment and worsened prior to his diabetes diagnosis in 2001. The examiner also opined that the Veteran's hypertension, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner stated that there is no correlation between the Veteran's worsening hypertension and any in-service illness injury or event. The examiner noted that at the time of the Veteran's enlistment in 1971, obesity/being overweight was thought to be the causative factor for his hypertension. The examiner stated that the Veteran remains overweight and this likely continues to contribute to his hypertension. The examiner indicated that she could determine the baseline level of severity of hypertension based upon medical evidence. The examiner noted that the current severity of the Veteran's hypertension was greater than the baseline. The examiner opined that the Veteran's hypertension was less likely as not aggravated beyond its natural progression by the Veteran's service-connected diabetes. The examiner stated that the Veteran's hypertension existed prior to enlistment and worsened prior to his diabetes diagnosis in 2001. The examiner expressed that the Veteran's hypertension was not worsened beyond its natural progression by his diabetes mellitus. After review of the January 2020 and September 2020 addendum opinion, the Board finds that the VA examiner failed to adequately discuss all the Veteran's contentions and provide supporting rationale for the conclusions reached. For example, with regards to whether the Veteran's hypertension was aggravated by the presumed exposure to herbicides, the examiner stated that hypertension is not a presumed herbicide exposure condition. However, as indicated in its December 2018 Board remand, that although hypertension is not listed as a disease associated with herbicide exposure under 38 C.F.R.§3.309(e), the governing regulations do not preclude the Veteran from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (1994). The Board is aware that the examiner opined that the Veteran's hypertension, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. However, the examiner's rationale was that there is no correlation between the Veteran's worsening hypertension and any in-service illness injury or event. The Board failed to discuss and consider the Veteran's contention regarding presumed herbicide exposure. In addition, with regards to whether the Veteran's hypertension was aggravated by the Veteran's service-connected diabetes, the examiner stated that the Veteran's hypertension existed prior to enlistment and worsened prior to his diabetes diagnosis in 2001. Although, the examiner opined that the Veteran's hypertension worsened prior to his diabetes, there is no indication or discussion on whether the Veteran's hypertension aggravated after the Veteran's diabetes diagnosis. In addition, in a previous VA examination, the examiner expressed that the Veteran's hypertension was not secondary to his diabetes because there was no renal insufficiency to suggest an aggravating trigger of hypertension. See March 2011 and June 2012 VA examinations. However, since then, the Veteran has been granted service connection for diabetic nephropathy. Thus, the opinion and the rationale of the examiner is not sufficient with regard to the issue of service connection for hypertension. See Nieves-Rodriguez, 22 Vet. App. 295, 301 (2008) (noting that "[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion... that contributes probative value to a medical opinion"). On remand, the Veteran should be provided an addendum opinion with regards to his service connection claim. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Thereafter, obtain an addendum opinion from a VA examiner, other than the January 2020/September 2020 VA examiner, or if necessary, schedule the Veteran for an examination with an appropriate specialist concerning his hypertension. The Veteran's claims file and a copy of this remand must be provided to the examiner for review, and the examination reports should reflect review of these items. The examiner must opine as to: (a) Whether there is clear and unmistakable (obvious and manifest) evidence demonstrating that the Veteran's hypertension existed prior to his entry into active duty? (b) If the answer to (a) is "Yes," is there clear and unmistakable (obvious and manifest) evidence demonstrating that the Veteran's hypertension was not aggravated (i.e., the underlying disability was not increased in severity) beyond its normal progression during his period of active duty, to include as a result of conceded herbicide exposure? (c) If the Veteran's hypertension did not clearly and unmistakably exist prior to service, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that such hypertension is etiologically related to the Veteran's active service, to include as due to exposure to herbicides. (Continued on the next page) (d) The examiner should also provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that his hypertension was aggravated by or chronically worsened by the Veteran's service-connected diabetes mellitus. In addressing these questions, the examiner must consider and discuss the Veteran's assertions. All rendered opinions must be accompanied by a thorough rationale. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M.D. 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.