Citation Nr: 21040602 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 17-20 492 DATE: July 6, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus type II (DM) and/or coronary artery disease (CAD), or as due to exposure to herbicide agents and/or contaminated water at Camp LeJeune, is remanded. Entitlement to service connection for erectile dysfunction (ED), to include as secondary to hypertension, or as due to exposure to herbicide agents and/or contaminated water at Camp LeJeune, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from December 1968 to September 1975, to include service at Camp Lejeune and service in the Republic of Vietnam. The case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2013 rating decision. In March 2021, the Veteran testified before the undersigned Veterans Law Judge at a videoconference hearing. The Veteran's wife was also present for the hearing and testified on behalf of the Veteran. A transcript of the hearing is of record. By way of background, the Veteran's claim for service connection for hypertension and erectile dysfunction was received in February 2012. In his claim, the Veteran contended that his ED began in January 2002 and his hypertension, initially claimed as high blood pressure, began in January 2006. In his initial claim for service connection, the Veteran contended that his ED was related to herbicide exposure. See February 2012 VA Form 21-526. Veteran has also contended that his ED is secondary to hypertension, that his ED started after his hypertension treatment began, and that he began receiving treatment for his hypertension after his stent operation in 2006. See December 2013 Notice of Disagreement. During his March 2021 hearing, the Veteran and his wife testified that the Veteran had been diagnosed with hypertension three to four years after service and that after his discharge from service in 1975 he was not using VA but was instead seeing a private doctor. He testified that he feels his hypertension is due to service on a secondary basis to his diabetes or his coronary artery disease and also because he was in Vietnam, where he was exposed to herbicide agents, and at Camp LeJeune, where he was exposed to contaminated water. The Veteran testified that he was stationed at Camp LeJeune for two years as an office clerk. With respect to his ED, the Veteran and his wife testified that it has been a problem on and off for 40 years, he first noticed it when he came back from Vietnam, and it has been a longstanding problem since his discharge. He testified that he had received a lot of private care in addition to care through VA and that he was not able to tell whether all of his private records had been submitted. To assess the etiology of the Veteran's hypertension, the AOJ scheduled the Veteran for a VA examination in May 2019. The record reflects that he failed to report to the May 2019 VA examination. During his March 2021 hearing, the Veteran testified he had not attended the May 2019 VA examination as it was scheduled during a time when his wife was in the hospital for a leg amputation and surgery and subsequent rehab. He testified that he had not received notice of his examination because he was not home to receive mail during that time. The Veteran further testified that he would be available for a rescheduled examination. See March 2021 Hearing Transcript. The Board cannot make a fully-informed decision on the issue of the Veteran's claimed hypertension because no VA examiner has opined regarding the nature, etiology, or current state of the Veteran's hypertension. The Board finds that the Veteran has presented good cause for failing to attend his examination and will remand for the scheduling of a new examination. The Board notes that in November 2018, the National Academy of Sciences (NAS) moved hypertension from the "limited or suggestive" to "sufficient" category for association with herbicides. Veterans and Agent Orange: Update 11 (2018). On remand, an opinion should be obtained addressing whether the Veteran's hypertension may be directly related to such exposure. With respect to the Veteran's claim for service connection for ED, the Veteran was afforded a series of VA examinations in September 2013, including a VA Diabetes Mellitus examination as well as a VA Male Reproductive System Conditions examination. As a result of these examinations, the VA examiner noted that the Veteran had ED and opined that it was at least as likely as not (at least a 50 percent probability) due to diabetes mellitus. The VA examiner also noted that, per the Veteran, he had ED since 2001, but that it was worse since 2005; and he was diagnosed with ED in 2005. The September 2013 VA Diabetes Mellitus examination indicates that, per the Veteran's wife, the Veteran was diagnosed with diabetes mellitus type II in 2005. The September 2013 VA examiner opined that the Veteran's ED was as likely as not (at least a 50 percent probability) attributable to his diabetes mellitus type II diagnosis, including residuals of treatment for this diagnosis. See September 2013 VA Diabetes Mellitus examination report; see also September 2013 VA Male Reproductive System Conditions examination report. Following the September 2013 VA examinations, the AOJ obtained an addendum opinion regarding the claim for ED related to diabetes and noted that the Veteran's ED was noted several years prior to the diagnosis of diabetes. The October 2013 VA examiner opined that low testosterone would more likely than not be the primary cause of ED unrelated to diabetes, and that it was more likely than not that the diabetes did not cause and did not aggravate the ED beyond normal progression but the dysfunction is solely due to natural progression of factors unrelated to service-connected diabetes. See October 2013 VA medical opinion. The opinions described above, both for and against a relationship between the Veteran's ED and his diabetes, are not adequately explained, and the Board believes a new opinion should be obtained on remand that is responsive to all the Veteran's contentions. In addition, as discussed above, the Veteran has raised alternate theories of contention which have not been addressed, including that his ED may be secondary to hypertension or due to exposure to herbicide agents and/or contaminated water at Camp LeJeune. While on remand, the Veteran should be offered the opportunity to submit any outstanding private treatment records or authorize VA to obtain them on his behalf. Similarly, any outstanding VA treatment records should be obtained and associated with the file. The matters are REMANDED for the following action: 1. Associate any outstanding VA treatment records dated with the Veteran's claims file. 2. Give the Veteran the opportunity to identify any outstanding pertinent evidence that has not already been associated with the claims file. The AOJ should then attempt to obtain those records if the Veteran provides the appropriate authorization. 3. Schedule the Veteran for a VA examination with an appropriate medical professional to determine the nature, etiology, and current state of the Veteran's claimed hypertension disability. The entire claims file should be sent to and reviewed by the VA examiner, and the examiner should take a history from the Veteran as to the progression of his hypertension disability. Upon review of the evidence of record, including the lay statements from the Veteran and his wife, the examiner is asked to address the following: (a) Is it at least as likely as not (approximately 50 percent probability) that the Veteran has a current hypertension disability that had onset in, or is otherwise related to the Veteran's period of active duty service, to include as due to exposure to herbicide agents during service in Vietnam and/or contaminated water at Camp LeJeune? In providing a response, the examiner should consider and comment upon the November 2018 NAS study that moved hypertension from the "limited or suggestive" to "sufficient" category for association with herbicides. (b) Is it at least as likely as not (a 50 percent or higher probability) that the Veteran's hypertension was caused or aggravated by his service-connected diabetes mellitus type II? In this regard, the Board notes that causation and aggravation are two separate inquiries, and both must be answered. (c) Is it at least as likely as not (a 50 percent or higher probability) that the Veteran's hypertension was caused or aggravated by his service-connected coronary artery disease? In this regard, the Board notes that causation and aggravation are two separate inquiries, and both must be answered. A clearly-stated rationale for any opinion offered should be provided. 4. Schedule the Veteran for a VA Male Reproductive Systems Conditions examination. The examiner should review the entire claims file, to include a copy of this Remand. The examiner should take a history from the Veteran as to the progression of his disability. Upon review of the evidence of record, including the lay statements from the Veteran and his wife, the examiner is asked to address the following: (a) Is it at least as likely as not (approximately 50 percent probability) that the Veteran's erectile dysfunction disability had onset in, or is otherwise related to service, to include as due to exposure to herbicide agents during service in Vietnam and/or contaminated water at Camp LeJeune? (b) Is it at least as likely as not that the Veteran's erectile dysfunction disability was caused or aggravated by the hypertension disability that is currently on appeal? In this regard, the Board notes that causation and aggravation are two separate inquiries, and both must be answered. (c) Is it at least as likely as not that the Veteran's erectile dysfunction disability was caused or aggravated by his service-connected diabetes mellitus type II? In this regard, the Board notes that causation and aggravation are two separate inquiries, and both must be answered. In this connection, even if ED was present before diabetes, a discussion as to whether diabetes aggravated ED must still be provided. A clearly-stated rationale for any opinion offered should be provided. (Continued on Next Page) 5. Thereafter, readjudicate the remanded issues. If the benefits sought on appeal remain denied, provide the Veteran with a supplemental statement of the case and allow an appropriate period of time for response. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Fulmer, Associate 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.