Citation Nr: 21041985 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 16-51 617 DATE: July 10, 2021 REMANDED Entitlement to service connection for hypertension, to include as due to exposure to herbicide agents, is remanded. Entitlement to service connection for erectile dysfunction is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Navy from March 1968 to December 1969. His decorations include the National Defense Service Medal and the Vietnam Campaign Medal. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a June 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. In June 2019, the Veteran testified at a Board video-conference hearing before a Veterans Law Judge. A transcript of that hearing has been associated with the record. In September 2020, the Board remanded the issues currently on appeal to the agency of original jurisdiction (AOJ) for additional development. After taking further action, the AOJ confirmed and continued the prior denials and returned the case to the Board. In March 2021, the Board wrote the Veteran and his representative to inform them that the Veterans Law Judge who conducted the hearing in June 2019 was no longer employed by the Board. The Veteran was offered the opportunity to testify at another Board hearing, but declined. Although the Board sincerely regrets the additional delay, a remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claim and to afford him every possible consideration. 1. Entitlement to service connection for hypertension is remanded. The Veteran seeks to establish service connection for hypertension. He has asserted that his hypertension is secondary to his service-connected coronary artery disease and/or diabetes mellitus. Alternatively, he has contended that his hypertension is the result of exposure to herbicide agents in Vietnam. Pursuant to the September 2020 remand, the Veteran underwent a VA examination in October 2020. The examiner noted a diagnosis of hypertension and opined that hypertension was less likely than not proximately due to or the result of the Veteran's service-connected coronary artery disease or diabetes mellitus. The examiner further opined that it was less likely than not that the Veteran's hypertension was aggravated by his service-connected coronary artery disease or diabetes mellitus. As to whether hypertension might be directly related to exposure to herbicide agents in Vietnam, the examiner noted that "[a]lthough there is emerging evidence suggesting that hypertension may be caused by exposure to herbicides, the VA has not yet rendered this directive. At this time, it is not possible for this examiner to render an opinion as to whether or not this Veteran's hypertension is otherwise etiologically related to such service, to include the exposure to herbicide agents." See October 2020 VA Examination. Hypertension is not presumptively associated with herbicide exposure, including Agent Orange exposure. However, the National Academy of Sciences Institute of Medicine (NAS) recently indicated that "there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and herbicide exposure. See November 15, 2018 press release from NAS. Although presumptive service connection cannot be granted for the Veteran's hypertension, a veteran may establish service connection for hypertension based on exposure to herbicide agents with proof of actual direct causation. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to herbicide agents does not preclude direct service connection for other conditions based on such exposure); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Because the October 2020 examiner did not offer a clear opinion as to whether hypertension could be directly related to the Veteran's presumed exposure to herbicide agents in Vietnam, and did not otherwise offer a substantive explanation as to why such an opinion could not be provided without resort to speculation, an addendum opinion is required. 2. Entitlement to service connection for erectile dysfunction is remanded. The Veteran also seeks to establish service connection for erectile dysfunction. He has contended, in part, that his erectile dysfunction is the result of medication he takes to treat his hypertension. The Veteran's claim for service connection for hypertension could significantly impact a decision on his claim for service connection for erectile dysfunction; that is to say, the issues are inextricably intertwined. Harris v. Derwinski, 1 Vet. App. 180 (1991). As such, the Board will remand the erectile dysfunction claim as well. These matters are REMANDED for the following action: 1. Ask the Veteran to identify, and provide appropriate releases for, any care providers who may possess new or additional evidence pertinent to the issues on appeal. If he provides the necessary release(s), assist him in obtaining the records identified, following the procedures set forth in 38 C.F.R. § 3.159. Any new or additional (i.e., non-duplicative) evidence received should be associated with the record. If any of the records sought are not available, the record should be annotated to reflect that fact, and the Veteran and his representative should be notified. 2. Obtain copies of records pertaining to any VA treatment the Veteran has received since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record. 3. After the foregoing development has been completed to the extent possible, arrange to have a qualified clinician review the claims file for purposes of providing an addendum medical opinion addressing the likelihood that the Veteran's hypertension is related to his presumed in-service exposure to herbicide agents. If the examiner finds that another examination of the Veteran is required, one should be undertaken. After reviewing the record, the clinician should offer an opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the Veteran's hypertension had its onset in, or is otherwise attributable to, his period of active service, to include his presumed in-service exposure to herbicide agents. The examiner's opinion must reflect consideration of the Veteran's individual risk factors, as well as NAS's upgrade of hypertension to the "sufficient" category, indicating that "there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and herbicide exposure. A complete medical rationale for all opinions expressed must be provided. If an opinion cannot be provided without resorting to speculation, the examiner should a provide complete explanation as to why that is so. In so doing, the examiner is requested to explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or whether the limits of current medical knowledge have been exhausted in providing an answer to that particular question. If is it the examiner's conclusion that it is at least as likely as not that the Veteran's hypertension is attributable to service, the examiner should offer a further opinion as to whether it is at least as likely as not that the Veteran's erectile dysfunction has been (a) caused or (b) aggravated (worsened beyond natural progression) by hypertension, to include medication taken for the treatment of hypertension. 4. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issues on appeal should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Joseph T. Leonard, 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.