Citation Nr: 22017780 Decision Date: 03/26/22 Archive Date: 03/26/22 DOCKET NO. 17-54 039 DATE: March 26, 2022 ORDER Entitlement to an initial disability rating in excess of 30 percent from June 19, 2015, for posttraumatic stress disorder (PTSD) is denied. Entitlement to an increased rating of 50 percent from January 22, 2018, but no earlier or greater, for PTSD is granted. Entitlement to service connection for erectile dysfunction, as secondary to service-connected prostate cancer is granted. REMANDED Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for hypertension, to include as due to herbicide exposure, PTSD, and prostate cancer is remanded. FINDINGS OF FACT 1. From June 19, 2015, to January 21, 2018, the Veteran's PTSD manifested in symptoms suggesting occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks but has not resulted in flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships suggesting occupational and social impairment with reduced reliability and productivity. 2. From January 22, 2018, the Veteran's PTSD manifested in symptoms suggesting occupational and social impairment with reduced reliability and productivity but has not resulted in suicidal ideation, obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships. 3. The Veteran's erectile dysfunction is proximately due to his service-connected prostate cancer. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial disability rating in excess of 30 percent from June 19, 2015, for posttraumatic stress disorder (PTSD) have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for entitlement to an increased rating of 50 percent from January 22, 2018, but no earlier or greater, for PTSD have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, DC 9411. 3. The criteria for entitlement to service connection for erectile dysfunction, as secondary to service-connected prostate cancer have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from February 1968 to December 1970. These matters come to the Board of Veterans' Appeals (Board) on appeal from September 2014 and January 2016 rating decisions issued by a VA Regional Office (RO). The Board notes the Veteran's VA Form 9 requested a hearing before the Board. The Veteran's representative subsequently withdrew said hearing request in a March 2021 correspondence. As such, his hearing request is considered withdrawn. 38 C.F.R. § 20.704. In addition, although evidence has been added to the claims file since the October 2017 statements of the case and a February 2019 rating decision, the Veteran submitted a December 2019 waiver of initial Agency of Original Jurisdiction (AOJ) review and requested that the Board proceed with adjudication his appeal. The Board further notes consideration has been given to whether the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) was reasonably raised by the record in this case. Rice v. Shinseki, 22 Vet. App. 447 (2009). While the Veteran's PTSD symptoms have been noted to interfere with his ability to work, there is no indication in the record that the Veteran is unable to obtain or maintain substantially gainful employment nor has he contended as such; indeed, the record indicates the Veteran worked in the trucking industry for over 40 years after service retiring in 2009. Afterwards, the Veteran reported continuing to work part-time five days a week for 3-4 hours a day delivering parts. Therefore, as the issue of a TDIU is not reasonably raised by the record, it is not part of the rating appeal and will not be further addressed herein. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Increased Rating 1. Entitlement to an initial disability rating in excess of 30 percent from June 19, 2015, for posttraumatic stress disorder (PTSD), is denied. 2. Entitlement to an increased rating of 50 percent from January 22, 2018, but no earlier or greater, for PTSD is granted. At the outset, the Board notes, VA received the Veteran's intent to file a claim for benefits on June 19, 2015. The Veteran timely appealed the initial January 2016 rating decision stemming from said claim. Thus, the Board will consider the period on appeal beginning June 19, 2015, the date of the receipt of the Veteran's intent to file a claim for benefits. See 38 U.S.C. § 5110; 38 C.F.R. § 3.400. The Veteran contends his service-connected PTSD symptoms warrant a higher rating during the period on appeal. The RO awarded the Veteran an initial rating for his PTSD of 30 percent, effective June 19, 2015 (reflecting the date VA received his intent to file). For reasons outlined below, the Board finds an increased initial rating greater than 30 percent is not warranted, but the 50 percent rating can be awarded from January 22, 2018, but no earlier and no higher, for his PTSD manifestations. The Veteran's PTSD is rated under DC 9411, which indicates that PTSD should be rated under the General Formula for Mental Disorders (General Formula). The Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. Turning to the relevant evidence of record, the Veteran was afforded a VA examination in January 2016. At which time the examiner opined the Veteran's PTSD symptoms were productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. Symptoms were noted to include depressed mood, anxiety, suspiciousness, and chronic sleep impairment. The Veteran reported being married to his wife of 48 years and described their relationship as "fantastic". He enjoys time with his granddaughter and maintains good contact with his brother. The Veteran also reported not having much of a social life outside of his family and has begun to lose interest in hobbies. In his spare time, he does yard work, works a part-time job, watches TV, and goes grocery shopping. The Veteran reported no legal or substance abuse history. Observationally, the examiner noted the Veteran's affect was restricted and mood appeared dysphoric. He was polite and cooperative during examination and his eye contact, speech, and behavior were "normal". It was noted that the Veteran was capable of managing his own finances and that he functioned well in the workplace and got along well with his wife and family. The examiner noted the Veteran's memory was intact with no delusions or hallucinations or panic attacks. The Veteran denied experiencing any suicidal or homicidal ideations however the Veteran did endorse symptoms of feeling sad, anxious, and hypervigilant especially in public. Poor sleep and increased irritability were also noted however the Veteran reported medications did help. Additional VA treatment records indicate PTSD symptoms were stable and included anxiety, nightmares, and hypervigilance. See December 2016 Treatment notes. Further mental status examinations do not indicate additional symptoms or worsening of the Veteran's mental health. In February 2018, the Veteran submitted a private PTSD examination conducted by Dr. J.A. dated January 22, 2018. Dr. J.A. opined that the Veteran's PTSD manifested in occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and/or mood. Symptoms were noted to include depressed mood, anxiety, near continuous depression, chronic sleep impairment, mild memory loss, circumstantial, circumlocutory, or stereotyped speech, difficulty understanding complex commands, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Observationally, Dr. J.A. reported the Veteran was cooperative but tentative upon examination. His affect was normal with fair judgment and insight. Memory was "broadly intact", and he was noted to be oriented to time, place, and person. The Veteran denied anger problems, obsessions, and compulsions. He further denied experiencing any suicidal or homicidal ideations. Speech patterns were noted as coherent but "somewhat tangential and circumstantial". Lastly, Dr. J.A. opined that his current mental health condition would be rated as moderate to severe in nature. The Veteran was afforded another VA examination in November 2018 at which time, the examiner opined that the Veteran's PTSD would result in occupational and social impairment with reduced reliability and productivity. The examiner noted symptoms of depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, and disturbance of motivation and mood. The Veteran reported currently being married to his wife of 51 years and that he had two adult children and one grandchild. Overall, the Veteran reported maintaining good relationships with his family members. No substance abuse or legal issues were reported. Observationally, the Veteran was noted to be alert and fully oriented with appropriate affect. The Veteran's appearance, behavior, speech, and judgment were within normal limits. He was also noted as being capable of managing his own finances. Lastly, the examiner remarked that the Veteran had been additionally diagnosed with generalized anxiety disorder (GAD) as a result of his cancer diagnosis in 2014. Symptoms of his GAD included anxiety, panic attacks more than once a week, and mild memory loss. June 19, 2015, to January 21, 2018 Based on the evidence of record, the Board finds a rating in excess of 30 percent from June 19, 2015, to January 21, 2018, is not warranted. During this period, the evidence shows that the Veteran's PTSD symptoms included depressed mood, anxiety, and chronic sleep impairment productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks although generally functioning satisfactorily, with routine behavior, self-care, and conversation. These symptoms were corroborated by the evidence of record including the Veteran's statements of being tired with lost interest in hobbies and feelings of anxiety in public. During this period, the Board finds that the Veteran's disability is fully capable of evaluation under the rating schedule. In so finding, the Board also concludes the Veteran's PTSD symptoms during this period do not warrant a 50 percent disability rating as the Veteran has never demonstrated occupational and social impairment with reduced reliability and productivity due to symptoms of similar severity, frequency, or duration as to those contemplated by the 50 percent criteria. Indeed, the evidence of record lacks any mention of flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships. Indeed, the Veteran endorsed being married, and having a "good" relationship with his children and other family members. He also endorsed doing well in his part-time job and performing yard work, getting the groceries, and watching TV in his spare time. While the Veteran has generally contended that his symptoms should be assigned a 50 percent disability rating or even a 70 percent disability rating from the date of claim, the Board finds this is not supported by the evidence of record during this period. Rather, the Veteran's symptoms during this period more nearly approximate that of a 30 percent disability rating as previously assigned. From January 22, 2018 Upon review of the evidence of record, the Board finds a 50 percent disability rating, is warranted from January 22, 2018, but no earlier or greater. Indeed, January 22, 2018, marks the date upon which the Veteran's PTSD symptoms are first documented to note worsening PTSD symptoms. During the private examination conducted by Dr. J.A., symptoms were noted as including mild memory loss, near continuous depression, circumlocutory or stereotyped speech, difficulty understanding complex commands and impaired abstract thinking. Ultimately, Dr. J.A. found the Veteran had occupational and social impairment with deficiencies in most areas, to include work, school, and family relations. The Veteran was afforded a VA examination in November 2018 which corroborated an increased severity in PTSD symptoms namely panic attacks more than once a week, hyperarousal, avoidance, and negative alterations in cognition and mood. However, the examiner noted the Veteran's PTSD would result in occupational and social impairment with reduced reliability and productivity. Here, the Board finds the November 2018 VA examination to reflect the current severity of the Veterans PTSD symptoms more accurately. See D'Aries v. Peake, 22 Vet.App. 97, 107 (2008) (it is within the purview of the Board to evaluate the medical evidence and favor one medical opinion over another). Specifically, although Dr. J.A. noted the Veteran's social interactions with family, it appears he failed to adjust his opinion on the impact of his PTSD symptoms accordingly. Throughout the appeal period, the Veteran has reported to having a "fantastic" relationship with his wife and a good relationship with his adult children and grandchild. It is noted that he has become more socially isolated from others outside his family, however there is nothing in the record to suggest "he just sits at home with morose brooding" as Dr. J.A. summarizes. As such, the Board finds a rating in excess of 50 percent from January 22, 2018, is not warranted. However, based on January 22, 2018, private examination, the Board also finds this is the first date upon which the Veteran's complaints of worsening and additional symptoms were noted in his treatment records and later corroborated, for the most part, by the recent VA examination in November 2018. In so finding, the Board also decides a higher 70 percent rating is not warranted at any point during the appellate time period as the Veteran has never demonstrated suicidal ideation, obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately and affectively, unprovoked irritability with periods of violence, spatial disorientation, neglect of personal appearance or hygiene; difficulty adapting to stressful circumstances, nor an inability to establish and maintain effective relationships. Indeed, treatment records lack any reference to gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. Throughout the entire period on appeal, the Veteran has consistently denied experiencing suicidal or homicidal ideation. He has always been alert and oriented. Resolving any doubt in favor of the Veteran, the Board finds a 50 percent disability rating from January 22, 2018, but no earlier or greater for PTSD is warranted. The Board finds that at all times on appeal the Veteran's disability has been fully capable of evaluation under the rating schedule. Based on the above, an initial rating in excess of 30 percent from June 19, 2015, to January 21, 2018, for PTSD is not warranted. From January 22, 2018, however, a 50 percent rating, but no greater, for PTSD is warranted. In denying any further increased ratings / staged ratings, the Board finds the benefit of the doubt doctrine is not applicable as the weight of the evidence is against finding a higher rating is warranted. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to erectile dysfunction, as secondary to service-connected prostate cancer is granted. The Veteran contends that his erectile dysfunction is caused or aggravated by his service-connected prostate cancer. Secondary service connection may be granted for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). To prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). VA treatment records and examinations have confirmed the Veteran has been diagnosed with erectile dysfunction. The Veteran is also currently service-connected for prostate cancer and has been treated for the condition since March 2016. Therefore, the remaining question before the Board is whether there is a medical nexus between the Veteran's service-connected prostate cancer and his current erectile dysfunction. Regarding the medical nexus inquiry, the Veteran was afforded a VA examination in October 2017. At which time, the examiner opined that the Veteran's erectile dysfunction is not less likely than not proximately due to or the result of prostate cancer. The examiner noted that the medical evidence showed the Veteran's erectile dysfunction "predated the prostate disorder by more than 6 years". Therefore, "the cancer is not a likely cause of the [erectile dysfunction]". In support of his claim, the Veteran submitted a private medical opinion from his treating physician, Dr. R.H. dated October 2019. Dr. R.H. reported that he has treated the Veteran for prostate cancer since March 2016. He then opined that the Veteran's erectile dysfunction "most likely is related to [his] prostate cancer". Dr. R.H. explained that the Veteran's prostate cancer resulted in the loss of an entire side of his prostate gland in which, "a very high probability...affected the nerves that went to [the Veteran's] penis". This in turn, would result in erectile dysfunction. Dr. R.H. further explained, that prostate cancer may be present for many years prior to clinical detection. Therefore, "most likely [the Veteran's] ED is related to [his] prostate cancer even before its diagnosis". The Board finds the private opinion of Dr. R.H. to be highly probative and dispositive of the claim now on appeal. Dr. R.H.'s opinion was through, based on in-person treatment of the Veteran himself, and supported by an adequate rationale. The Board notes, Dr. R.H.'s opinion did not use the exact terminology used by VA. However, the overall intent of the opinion was clear and unmistakable. See McClaim v. Nicholson, 21 Vet.App. 321 (2007) (noting that although clarity is preferred, it "is not and cannot be demanded in every instance or finality would forever be delayed pending perfection in draftsmanship"). See also Parrish v. Shinseki, 24 Vet.App. 391, 401 (2011) (recognizing that a poorly drafted medical opinion is not necessarily inadequate if it can otherwise be understood). In contrast, the October 2017 VA medical opinion is inadequate for adjudicative purposes and must be afforded no probative weight. Specifically, the October 2017 VA examiner's opinion focused solely on causation and did not consider nor opine as to whether the Veteran's prostate cancer may have aggravated his erectile dysfunction. A medical opinion that addresses only causation and not aggravation is inadequate to adjudicate a claim for service connection on a secondary theory of entitlement based on aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). Furthermore, the examiner's rationale was based entirely on the timing of the Veteran's diagnosed conditions. As the Court explained in Frost v. Shulkin, however, there is no temporal requirement inherent in 38 C.F.R. § 3.310(a) even when the Veteran claims that the primary condition caused the secondary condition. 29 Vet. App. 131 (2017). Thus, it is not necessary for the primary condition to be service connected, or even diagnosed, at the time the secondary condition is incurred. It is quite possible, for example, that the Veteran's prostate cancer existed long before it was diagnosed and thus could still have caused erectile dysfunction as explained by Dr. R.H. Since the VA examiner's opinion was primarily based on the timing of the Veteran's prostate cancer diagnosis versus the erectile dysfunction diagnosis, the Board finds the rationale and therefore, the opinion as a whole inadequate. Therefore, the Board will turn to the remaining probative evidence of record. Accordingly, the Board finds the weight of the evidence indicates that the Veteran's erectile dysfunction was caused by his service-connected prostate cancer. The appeal is therefore, granted. REASONS FOR REMAND 4. Entitlement to service connection for bilateral hearing loss is remanded. 5. Entitlement to service connection for tinnitus is remanded. The Veteran contends his current bilateral hearing loss and tinnitus are related to his military service. Specifically, the Veteran asserts that he served with the 25th Infantry division in Ch Chi, Vietnam. While stationed there, he experienced daily hazardous noise from M16, 50 caliber, and howitzer fire along with helicopters. See October 2019 Correspondence. At the outset, the Board notes the Veteran's DD 214 and military personnel records confirm that he served in the Republic of Vietnam from May 1969 to April 1970 at a fire support base located in Ch Chi, Vietnam. Due to his service, he was awarded the Vietnam Service Medal with two Bronze Stars among other decorations. As a result, the Board finds the Veteran's lay reports of exposure to hazardous noise with later symptoms of tinnitus and hearing loss to be competent and credible given the circumstances of his service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The RO obtained a July 2014 VA examination and medical opinion prior to the rating decision on appeal. However, this medical opinion does not provide an adequate rationale regarding whether the Veteran's bilateral hearing loss and tinnitus had their onset in service or are otherwise related to service. To support her negative rationale, the examiner noted the Veteran's separation examination from October 1970 contained audiometric tests which revealed hearing within normal limits with no significant worsening of hearing acuity when compared to his entrance examination from May 1967. Lastly, the examiner stated "since hearing loss due to noise occurs at the time of the exposure and not subsequently, the Veteran's current loss is not caused or a result of active-duty noise exposure. However, hearing within normal limits at separation from service does not preclude service connection for a current hearing disability. Hensley v. Brown, 5 Vet.App. 155, 159-60 (1993). As such, a remand is warranted for a new VA medical opinion to consider the Veteran's in-service noise exposure, and also to render an opinion consistent with Hensley. Regarding tinnitus, the examiner stated, "since the two are related and since the hearing loss was less likely as not caused by his active-duty noise exposure, it is my opinion that the Veteran's tinnitus was also less likely as not caused by his noise exposure". Since the VA examiner has indicated the Veteran's hearing loss and tinnitus are interrelated, the claim for entitlement to service connection to tinnitus is inextricably intertwined and is remanded as well. 6. Entitlement to service connection for hypertension, to include as due to herbicide exposure, PTSD, and prostate cancer is remanded. The Veteran contends that his currently diagnosed hypertension is the result of his exposure to herbicides during service in Vietnam. In the alternative, the RO has developed the Veteran's claim to include the contentions that it is secondarily related to his service-connected prostate cancer and/or PTSD. At the outset, the Board notes the Veteran's DD 214 and military personnel records confirm that he served in the Republic of Vietnam from May 1969 to April 1970. Due to his service, he was awarded the Vietnam Service Medal with two Bronze Stars among other decorations. Therefore, he is entitled to the presumptions afforded to all Vietnam veterans for such service. 38 U.S.C. § 1116 (a)(1); 38 C.F.R. §§ 3.307 (a)(6). While the Veteran is presumed to have been exposed to Agent Orange herbicides, hypertension is not currently presumptively associated with Agent Orange exposure. See 38 C.F.R. § 3.309(e). Notwithstanding the presumption provisions, a claimant is not precluded from establishing service connection for a disability due to exposure to herbicide agents with proof of direct causation. Combee v. Brown, 34 F.3d at 1042; Ramey v. Brown, 9 Vet. App. 40, 44 (1996), aff'd sub nom, Ramey v. Gober, 120 F.3d 1239 (Fed. Cir. 1997), cert. denied, 118 S. Ct. 1171 (1998). As noted by the Court, denying service connection "on the basis that it is not likely there is any nexus to service solely because the statistical analysis does not support presumptive service connection, would, in effect, permit the denial of service connection simply because there is no presumptive service connection." See Polovick v. Shinseki, 23 Vet. App. 48 (2009). Further, although VA has not conceded a presumptive relationship between hypertension and Agent Orange, the National Academy of Sciences (NAS) has placed hypertension in a "sufficient evidence" category as of the 2018 Update. That is, although hypertension has not been added to the list of diseases presumptively associated with exposure to herbicide agents, the NAS has recognized "sufficient evidence" of an association between the two such that a correlation cannot be ruled out with reasonable confidence. The Federal Circuit has recently found that this NAS 2018 Update is in the constructive possession of the VA and, therefore, must be considered in the adjudication of appeals where it may be implicated. See Euzebio v. McDonough, 989 F.3d 1305 (Fed. Cir. 2021). As such, the Board finds a new VA opinion is needed before a decision may be rendered on the claim. The Board further notes, the record does contain a VA medical opinion from October 2017 which addressed the Veteran's secondary theory of service connection. However, upon further review, this opinion is found to be inadequate for adjudicative purposes. Specifically, the October 2017 VA examiner opined that the Veteran has "essential hypertension" and "by definition is not secondary to or caused by any other disease, including PTSD". "It is a primary disorder in and of itself". Lastly, the examiner noted that "the PTSD predated the development of hypertension by many years". The Board finds this opinion to be conclusionary and based on an inadequate rationale. See Stefl v. Nicholson, 21 Vet.App. 120, 124-25 (2007) (a mere conclusion by an examiner is insufficient to allow the Board to make a fully informed decision as to the probative value of the opinion). See also Horn v. Shinseki, 25 Vet.App. 231, 240-42 (2012) (stating that under caselaw "an unexplained conclusory opinion is entitled to no weight in a service-connection context"). The examiner failed to explain what is meant by "essential" hypertension other than to state its "by definition" a primary disorder. There was no specific discussion as to whether PTSD or other service-connected conditions namely, prostate cancer, could aggravate his hypertension. A medical opinion that addresses only causation and not aggravation is inadequate to adjudicate a claim for service connection on a secondary theory of entitlement based on aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). Furthermore, the examiner's rationale included reference to the timing of the Veteran's diagnosed conditions. As the Court explained in Frost v. Shulkin, however, there is no temporal requirement inherent in 38 C.F.R. § 3.310(a) even when the Veteran claims that the primary condition caused the secondary condition. 29 Vet. App. 131 (2017). Thus, it is not necessary for the primary condition to be service connected, or even diagnosed, at the time the secondary condition is incurred. It is quite possible, for example, that the Veteran's prostate cancer and/or PTSD existed long before it was diagnosed and thus could still have caused or aggravated his hypertension. Accordingly, the Board finds the October 2017 VA medical opinion is inadequate for adjudicative purposes. Therefore, while on remand, a medical opinion should be obtained to address the Veteran's secondary theory of service connection in relation to his prostate cancer and PTSD, if direct service connection from herbicide agent exposure is not found. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate VA clinician as to the Veteran's bilateral hearing loss and tinnitus. The clinician is asked to review the claims file and note that the case review took place. (a.) The clinician is asked to determine whether the Veteran's bilateral hearing loss is at least as likely as not etiologically related to his active service, to include conceded noise exposure during service. (b.) The clinician is asked to determine whether the Veteran's tinnitus is at least as likely as not etiologically related to his active service, to include conceded noise exposure during service. (c.) The clinician should focus specifically on whether the noise exposure in service caused any current hearing impairment. Facts and medical principles relied upon to arrive at an opinion should be set forth, including any principles relating to the possibility of a delayed onset of loss of acuity due to noise exposure in service. (d.) In considering any lay statements of record, the clinician should note that the Veteran is competent to attest to matters of which he had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the clinician should provide a fully reasoned explanation. (e.) The clinician is reminded that "hearing within normal limits at separation from service does not preclude service connection for a current hearing disability". Hensley v. Brown, 5 Vet.App. 155, 159-60 (1993). (f.) The examiner must provide a complete rationale for his or her opinions in the examination report. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of his hypertension. The entire claims file must be reviewed by the examiner. The examiner must provide an opinion as to the following: (a) Determine whether it is at least as likely as not that the Veteran's hypertension is related to service, including his presumed herbicide agent exposure during his service in Vietnam. A well-supported rationale must be provided. In so rendering the opinion, the clinician is reminded that the fact that hypertension is not on the presumptive list of conditions due to herbicide agent exposure cannot by itself be the sole basis for a negative nexus opinion. Rather, the clinician should consider the Veteran's specific military history, medical history, risk factors, and any other circumstances deemed relevant by the clinician in rendering an opinion. Further, the examiner is also asked to consider "Update 2018" from the National Academy of Sciences that indicates "sufficient evidence" of an association between hypertension and herbicide agent exposure in rendering an opinion. See NAS 2018 Update. (b) Determine whether it is at least as likely as not that the Veteran's hypertension was proximately caused or aggravated (i.e., worsened beyond natural progression) by his service-connected PTSD and/or prostate cancer. The clinician is reminded that the term "aggravated" as used in 38 C.F.R. § 3.310(b), does not require that there be "permanent worsening" of the nonservice-connected disability. Instead, secondary service connection is warranted for "any incremental increase in disability and any additional impairment of earning capacity in nonservice-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase regardless of its permanence." See Ward v. Wilkie, 31 Vet. App. at 239. The clinician is also reminded that there is no temporal requirement for secondary service-connection and merely because hypertension is diagnosed before PTSD and/or prostate cancer cannot be the sole basis of a negative opinion (as it is quite possible, for example, that the claimed primary condition(s) could have existed long before it was diagnosed and thus could still have caused or aggravated his hypertension). (Continued on the next page) In other words, a complete and fully explanatory rationale should be provided for any opinion. If any opinion cannot be rendered without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, by a deficiency in the record, or because the examiner does not have the needed knowledge or training 3. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. F. Minnitte, Attorney Advisor 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.