Citation Nr: 21040968 Decision Date: 07/07/21 Archive Date: 07/07/21 DOCKET NO. 09-08 515 DATE: July 7, 2021 ORDER Service connection for hypertension is granted. Service connection for erectile dysfunction is granted. REMANDED Entitlement to service connection for an eye disability is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. FINDINGS OF FACT 1. The evidence shows the Veteran's hypertension is due to his presumed exposure to herbicide agents in service. 2. The Veteran's erectile dysfunction is due to his hypertension. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.307. 2. The criteria for service connection for erectile dysfunction have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Marine Corps from November 1965 to November 1967. He is a recipient of the Purple Heart. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" also known as the "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). If a veteran served in the Republic of Vietnam during the period from January 9, 1962, to May 7, 1975, he or she will be presumed to have been exposed to herbicide agents. 38 C.F.R. § 3.307(a)(6). Certain diseases will be presumed service-connected if a veteran was exposed to herbicide agents in service, even if there is no record of the disease during service. 38 C.F.R. §§ 3.307(a)(6), 3.309(e). Additionally, even if a disease is not considered presumed service-connected to exposure to herbicide agents, VA should still address whether there could be a direct link between the Veteran's diagnosis and herbicide exposure. See Combee v. Brown, 34 F.3d 1039, 1042-43 (Fed. Cir. 1994); McCartt v. West, 12 Vet. App. 164, 167 (1999). The Board must consider all the evidence of record and make appropriate determinations of competence, credibility, and weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). When there is an approximate balance of positive and negative evidence regarding any material issue, all reasonable doubt is resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 1. Service connection for hypertension Based on the evidence, the Board finds the criteria for service connection for hypertension have been met. 38 C.F.R. § 3.303. The record shows the Veteran has hypertension currently. Specifically, VA examiners diagnosed hypertension in June 2012 and August 2020. VA treatment records also show treatment for hypertension. Thus, the first element of service connection is satisfied. See Holton, 557 F.3d at 1366. Next, the Veteran was exposed to herbicide agents in service. His service personnel records show he served in the Republic of Vietnam from May 1966 to June 1967. As this service falls within the presumptive period, the Veteran is presumed to have been exposed to herbicide agents during his service. See 38 C.F.R. § 3.307(a)(6). Finally, the evidence shows the Veteran's hypertension is due to exposure to herbicide agents. The April 2021 examiner opined that the Veteran's hypertension is at least as likely as not due to exposure to herbicide agents. The examiner explained that the most recent update from the National Academy of Sciences in November 2018 has established Agent Orange as an accepted primary etiology of hypertension, and there are no more likely alternate etiologies for the Veteran's hypertension. The June 2016 VA examiner noted the Veteran's hypertension was without a known etiology. The Board finds the April 2021 examiner's highly probative as it considered alternate etiologies and provides an explanation for the conclusion. With a current disability, in-service exposure, and a positive nexus, all elements of service connection are shown. See Holton, 557 F.3d at 1366. Service connection for hypertension is warranted. 2. Service connection for erectile dysfunction Service connection may also be granted on a secondary basis for a disability that is proximately due to or the result of (caused) or worsened beyond its natural progression (aggravated) by a service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448-49 (1995) (en banc). After reviewing the record, the Board finds the criteria for service connection for erectile dysfunction have been met. 38 C.F.R. §§ 3.303, 3.310. The evidence shows the Veteran suffers from erectile dysfunction. VA examiners in May 2010 and June 2012 diagnosed erectile dysfunction. VA treatment records also show diagnosis of erectile dysfunction. The May 2010 examiner wrote it was more likely than not that the Veteran's erectile dysfunction was due to his longstanding hypertension. Similarly, the June 2012 examiner stated that the usual cause of erectile dysfunction is vascular, typically from hypertension or hypertension medications, which would be the obvious cause in the Veteran's case. The June 2016 examiner again found the cause of the Veteran's erectile dysfunction was vascular, specifically his longstanding hypertension and medications for hypertension. The Board finds this clear consensus highly probative that the Veteran's erectile dysfunction is due to his now service-connected hypertension. Service connection for erectile dysfunction is warranted on a secondary basis. REASONS FOR REMAND 1. Entitlement to service connection for an eye disability is remanded. The claim of service connection for an eye disability has been remanded by the Board in May 2013, denied in May 2018, remanded by the Court in April 2019, and remanded by the Board in December 2019 and March 2021. Unfortunately, remand is again required to obtain clarification of the medical opinions of record. In the December 2019 and March 2021 remands, the Board requested medical opinions on the Veteran various eye diagnoses. In the December 2020 and March 2021 medical opinions, the examiners provided negative opinions on the relationship of current eye disabilities to service and noted intraocular implant of the left eye and posterior subcapsular cataract were due to a blow to the left brow. The Veteran has reported a head injury in service when he was exposed to an explosion that caused several injuries. Given the opinions against a nexus to service, it is unclear when the examiners believe the blow to the left eyebrow occurred. The March 2021 examiner noted the Veteran was hit by a branch but did not further explain the circumstances of this incident. Clarification is needed. Additionally, the March 2021 examiner noted ocular hypertension bilaterally. An opinion is needed to address whether ocular hypertension is at least as likely as not caused or aggravated by service-connected hypertension. See Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). 2. Entitlement to service connection for GERD is remanded. The claim of service connection for GERD was remanded by the Board in November 2016, denied in May 2018, remanded by the Court in April 2019, and remanded by the Board in December 2019 and March 2021. The most recent remand found the issue intertwined with the issue of service connection for hypertension, because the Veteran reported his blood pressure medication could sometimes aggravate his reflux during the May 2010 examination. A medical opinion is needed to determine if the Veteran's GERD is at least as likely as not caused or aggravated (worsened) by his service-connected hypertension. See Allen, 7 Vet. App. at 439. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA treatment records. 2. Obtain a medical opinion for the diagnoses of intraocular implant of the left eye, posterior subcapsular cataract, and ocular hypertension. The medical expert should review the claims file and address the following: (a.) Are left eye intraocular implant and posterior subcapsular cataract at least as likely as not due to head trauma in service, which has been conceded? If you believe the Veteran had trauma to the head or eye after service, please identify the source of such information. (b.) Is ocular hypertension at least as likely as not caused by service-connected hypertension? (c.) Was ocular hypertension at least as likely as not aggravated (worsened) by service-connected hypertension? If aggravation is found, provide a baseline level of disability prior to aggravation. Consider all relevant lay and medical evidence. All opinions must be supported by detailed rationale. If the opinion cannot be provided without resort to speculation, the expert should explain why, and state whether the inability is due to the absence of evidence or limits of scientific/medical knowledge. 3. Obtain a medical opinion for the Veteran's GERD. The expert should review the claims file and address whether the Veteran's GERD is at least as likely as not caused by his service-connected hypertension and whether his GERD was at least as likely as not aggravated (worsened) by his hypertension. The expert should consider all relevant lay and medical evidence, including the Veteran's reports during the May 2010 examination that the medication for hypertension sometimes aggravated his reflux. If aggravation is found, the expert should provide a baseline level of disability prior to aggravation. All opinions must be supported by detailed rationale. If the opinion cannot be provided without resort to speculation, the expert should explain why, and state whether the inability is due to the absence of evidence or limits of scientific/medical knowledge. A. S. CARACCIOLO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.P. Armstrong 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.