Citation Nr: 21032402 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 14-20 001A DATE: May 27, 2021 REMANDED Entitlement to service connection for hypertension, to include as due to in-service exposure to an herbicide agent, is remanded. Entitlement to service connection for vascular dementia, to include as due to in-service exposure to an herbicide agent, is remanded. Entitlement to special monthly compensation (SMC) based on aid and attendance or housebound status is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) from March 18, 2016, is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1966 to October 1970. These matters come to the Board of Veterans' Appeals (Board) on appeal from November 2013 and July 2017 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The issues of entitlement to a TDIU prior to April 18, 2014 and from March 18, 2016 were remanded by the Board in September 2016 for further development. In June 2020, this appeal was merged with the Veteran's appeals for service connection for hypertension and vascular dementia and SMC. These issues were remanded by the Board in June 2020. Having reviewed the record evidence, and although the Board is reluctant to contribute to "the hamster-wheel reputation of Veterans law" by remanding this appeal again, additional development is required before the underlying claims can be adjudicated on the merits. Cf. Coburn v. Nicholson, 19 Vet. App. 427, 434 (2006) (Lance, J., dissenting) (finding that repeated remands "perpetuate the hamster-wheel reputation of Veterans law"). Entitlement to service connection for hypertension and for vascular dementia, each to include as due to in-service exposure to an herbicide agent The Veteran's claims for service connection for hypertension and vascular dementia were remanded in a prior June 2020 Board remand. In this remand, the Board requested VA examinations and opinions be provided with regard to the etiology of both disabilities. With regard to hypertension, the Veteran was provided a VA examination and opinion in February 2021. The examiner opined that the Veteran's hypertension was less likely than not incurred in or caused by herbicide exposure during service as, per the VA, hypertension is not an illness caused by Agent Orange Exposure. The Board finds that, considering the National Academy of Sciences, Engineering and Medicine's (NAS) Update 2018, a remand is necessary to obtain an addendum opinion to the February 2021 VA hypertension Disability Benefits Questionnaire (DBQ). As noted in "Veterans and Agent Orange: Update 11 (2018)" (NAS 2018 Update), the NAS found sufficient evidence of an association for hypertension and exposure to Agent Orange and other herbicides used during the Vietnam War. The NAS 2018 Update upgraded hypertension to "sufficient" evidence of an association between this disability and in-service exposure to an herbicide agent. According to the NAS 2018 Update, "[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and in-service exposure to an herbicide agent. In light of the NAS 2018 Update, the Board finds that this issue must be remanded for an addendum opinion. With regard to vascular dementia, the Veteran was provided a VA behavioral health/mental health examination in January 2021 and a VA opinion. The examiner concluded that a definitive diagnosis of vascular dementia was beyond the scope of a behavioral health examination and required additional testing, including brain scans (or an magnetic resonance imaging (MRI) scan), to confirm a diagnosis. This examiner also concluded that he was unable to provide the requested medical opinion. The Board notes that the Veteran previously had an MRI scan of the brain in January 2017. The February 2021 VA examiner did not address this MRI and references to probable vascular disorders in the Veteran's brain noted following this MRI. Therefore, the Board finds this issue must be remanded for an addendum opinion. Entitlement to SMC and a TDIU after March 18, 2016 The Veteran also contends that he is entitled to SMC and to a TDIU after March 18, 2016. A decision on the service connection claims being remanded in this appeal likely will impact the issues of entitlement to SMC and to a TDIU from March 18, 2016. Thus, the Board finds that all of these issues are inextricably intertwined. See Henderson v. West, 12 Vet. App. 11, 20 (1998), citing Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that two issues are inextricably intertwined when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). Thus, adjudication of the Veteran's SMC and TDIU claims must be deferred. The RO also should attempt to obtain the Veteran's updated treatment records. The matters are REMANDED for the following action: 1. Conduct any appropriate development to obtain the Veteran's updated treatment records. 2. Forward the claims file and a copy of this REMAND to the clinician who conducted the February 2021 VA hypertension DBQ or another appropriate clinician for an addendum opinion concerning the etiology of the Veteran's hypertension. The Veteran does not need to report for examination. Based on a review of the claims file, the clinician is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that hypertension is related to the Veteran's active service, to include his presumed in-service exposure to an herbicide agent. A rationale must be provided for any opinion(s) expressed. If any requested opinion(s) cannot be provided without resorting to speculation, then the clinician should explain why this is so. The clinician is advised that the Veteran likely was exposed to an herbicide agent during active service. The clinician also is advised that, in "Veterans and Agent Orange: Update 11 (2018)," the National Academy of Sciences (NAS) concluded that there is "sufficient" evidence of an association between hypertension and in-service exposure to an herbicide agent. 2. Forward the claims file and a copy of this REMAND to the clinician who conducted the January 29, 2021, VA mental health/behavioral health DBQ or another appropriate clinician for an addendum opinion concerning the etiology of the Veteran's vascular dementia. The determination of whether the Veteran should report for an MRI scan of the brain and/or an examination is left to the discretion of the clinician asked to provide the opinion. Based on a review of the claims file, the clinician is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that vascular dementia, if diagnosed, is related to active service. A rationale must be provided for any opinion(s) expressed. If any requested opinion(s) cannot be provided without resorting to speculation, then the clinician should explain why this is so. The clinician is asked to consider the January 2017 MRI and references to probable vascular disorders in the Veteran's brain noted following this MRI in preparing his or her own opinion. 3. If, and only if, the clinician asked to provide the addendum opinion concerning vascular dementia determines that the January 2017 MRI is inconclusive or insufficient to provide a definitive diagnosis of vascular dementia, then the Veteran should be scheduled for another MRI and/or VA examination, if necessary, to clarify a diagnosis of vascular dementia. 4. Readjudicate the appeal. MICHAEL T. OSBORNE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Nadia Kamal, 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.