POSTTRAUMATIC STRESS DISORDER (PTSD)

C. BOSELY · 2019 · Case ID: 19157577

MIXED

Summary

The Veteran, who served from June 1948 to April 1952 and again from November 1954 to July 1971, with service in Korea and Vietnam, appeals the denial of service connection for a left knee disorder and the cause of death, and the remand of claims for Parkinson's disease and the cause of death. The Veteran's surviving spouse is the appellant. The Board granted service connection for Posttraumatic Stress Disorder (PTSD), finding that the Veteran's combat service in Vietnam, evidenced by a mortar attack and confirmed by his Combat Medical Badge, established the in-service stressor. Despite conflicting medical opinions, the Board resolved reasonable doubt in the Veteran's favor, granting PTSD. Service connection for bilateral hearing loss was also granted. The Veteran testified to hearing loss and exposure to acoustic trauma during combat in Vietnam, and his personnel records confirmed combat service and awards. Although a VA examiner opined the hearing loss was not service-related due to lack of immediate onset, the Board found the evidence in equipoise, granting the claim due to the Veteran's credible history and combat-related acoustic trauma. Service connection for a left knee disorder was denied. The Veteran claimed an in-service injury from falling into a drainage ditch in Vietnam, but service treatment records were silent regarding knee complaints. A private treatment record indicated presumed degenerative joint disease, and a VA orthopedic surgeon opined the injury was likely a sprain, not severe enough to cause the later diagnosed osteoarthritis, and that the Veteran would have reported a more significant injury. The Board found this expert opinion more probative, denying the claim. The claims for Parkinson's disease and the cause of death were remanded for further development. For Parkinson's, the Board noted conflicting evidence on diagnosis but a potential nexus to Agent Orange exposure based on NAS updates, requiring an opinion on Parkinson-like conditions and their relation to exposure. For the cause of death, the Board noted the death certificate listed cerebrovascular accident and dementia, and that hypertension was upgraded in NAS updates regarding Agent Orange association, requiring an opinion on whether hypertension and cerebrovascular accident were related to Agent Orange exposure.

Rationale

Combat service confirmed; Conflicting medical opinions; Benefit of the doubt applied

Special Benefit

NO SPECIAL BENEFIT

Docket No.

1300293

Full Decision Text

Citation Nr: 19157577
Decision Date: 07/24/19 Archive Date: 07/24/19

DOCKET NO. 1300293
DATE: July 24, 2019

ORDER

Service connection for posttraumatic stress disorder (PTSD) is granted.

Service connection for bilateral hearing loss is granted.

Service connection for a left knee disorder is denied.

REMANDED

Service connection for Parkinson’s disease, to include as due to exposure to herbicides, is remanded.

Service connection for the cause of the Veteran’s death is remanded.

FINDINGS OF FACT

1. The evidence is in equipoise in establishing that the Veteran had PTSD as a result of his combat related in-service stressors.

2. The evidence is in equipoise in establishing that the Veteran had bilateral hearing loss which had its onset during service.

3. The weight of the evidence establishes that the Veteran’s left knee disorder did not likely have its onset during service and was not otherwise related to service.

CONCLUSIONS OF LAW

1. The criteria for service connection for PTSD have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304.

2. The criteria for service connection for bilateral hear hearing loss have been met. 38 U.S.C. §§ 1110, 1131, 1131, 1154(b), 5107; 38 C.F.R. §§ 3.102, 3.303, 3.385.

3. The criteria for service connection for a left knee disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from June 1948 to April 1952 and from November 1954 to July 1971. He died in December 2014. The appellant is his surviving spouse. She has been substituted with regard to the claims pending at the time of the Veteran’s death.

The case is on appeal from June 2010, March 2011 and July 2015 rating decisions.

In October 2014, the Veteran testified at a Board hearing.

In July 2017, the claims came before the Board and were remanded for further development.

SERVICE CONNECTION

General Legal Criteria

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: “(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.” Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)).

1. Service connection for PTSD.

Service connection for PTSD specifically requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., under the criteria of DSM); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). If, such as here, the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304 (f)(2).

The appellant contends the Veteran met the criteria for a diagnosis of PTSD during his lifetime and that the disability was related to service, including his exposure to combat. Specifically, the appellant asserts that during the Veteran’s service in Vietnam, his unit received a mortar attack at night. The Veteran reported he fell into a drainage ditch and was very frightened. His service personnel records confirmed that he served in Korea and Vietnam and was awarded the combat medical badge.

As
, and provided the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304 (f)(2).

As the Veteran had confirmed combat service, his in-service stressor was established. Thus, the remaining questions are whether the Veteran had a valid diagnosis of PTSD under the DSM-5 criteria, and whether that diagnosis is related to his in-service stressors.

An August 2009 medical opinion was received from P.P., a licensed professional counselor. He indicated the Veteran was exposed to combat during service, including “death, destruction, blown away body parts, etc.” He reported while stationed in Vietnam, the Veteran was exposed to a mortar barrage which caused him abject terror and total helplessness. He stated the Veteran had a clinical diagnosis of PTSD, which caused impairment in his social family and other areas of functioning in his life. An additional August 2009 record from a counselor indicated the Veteran was diagnosed with PTSD and a November 2009 medical record noted he “obviously” had PTSD.

Thereafter, the Veteran was afforded a March 2010 VA examination in which the examiner, a psychologist, found that the Veteran did not have a diagnosis of PTSD. She stated the Veteran endorsed some symptoms of PTSD but did not meet the full criteria for a diagnosis of PTSD. She opined the Veteran’s cognitive problems were due to dementia rather than PTSD.

A September 2012 private medical opinion was provided by a psychiatrist who indicated the Veteran’s health had gradually deteriorated and his vulnerability increased, along with the prominence of his combat related PTSD. The examiner noted that the Veteran reported ongoing PTSD presenting problems, including concerns associated with combat memories.

An additional VA examination was provided in February 2013. The examiner concluded the Veteran did not have a diagnosis of PTSD that conformed to DSM criteria. He noted the Veteran’s symptoms did not meet the diagnostic criteria for PTSD, although he was diagnosed with dementia, not otherwise specified (NOS). The examiner reported that he reviewed the prior psychiatric evaluation provided to the Veteran in September 2012, and determined the evaluation was inadequate. He stated the opinion did not identify the onset of the Veteran’s PTSD, the stressor that led to PTSD, the symptoms connected to the diagnosis, nor did it include testing or an indication of how many times the physician examined the Veteran during his lifetime. Given the lack of symptom enumeration or connection between the symptoms and the stressor, the lack of explanation for the lengthy delay of onset, the prior examination findings, as well as his own examination findings, the examiner concluded the Veteran did not have a PTSD diagnosis.

The examiner further opined the Veteran met the criteria for experiencing a traumatic event, but did not meet the reexperiencing, avoidance, or arousal criteria. He noted the Veteran had no treatment for PTSD for approximately 40 years after service and there is no explanation of how PTSD symptoms could lie dormant for this long. He indicated medical research shows delayed onset of PTSD is rare, delayed onset with no prior symptomatology is even rarer, and the combination of no symptoms for approximately 40 years with then a full clinical presentation is “almost unheard of.”

Following the May 2014 Board remand, the Veteran was afforded an October 2014 Board hearing. The Veteran testified that he believed he had a current diagnosis of PTSD related to service and the appellant, a medical professional, also indicated that the criteria for PTSD were met.

The Board remanded the claim in July 2017 for further development. Thereafter, a July 2018 medical opinion was provided by a neuropsychologist who indicated a diagnosis of PTSD for the Veteran was not well supported. She opined psychiatric symptoms are identified in his record (irritability, emotional detachment), although as found in the prior VA examination reports, the Veteran did not meet the full criteria for PTSD. She indicated his functioning was not impaired due to his symptoms. She further noted the March 2010 examination report found his irritability was due to his circumstances at the time and his emotional detachment was consistent with his upbringing.

After a careful review of the evidence of record, the Board finds that service connection for PTSD is warranted. Different providers have offered conflicting opinions as to whether the Veteran had PTSD
, a July 2018 medical opinion was provided by a neuropsychologist who indicated a diagnosis of PTSD for the Veteran was not well supported. She opined psychiatric symptoms are identified in his record (irritability, emotional detachment), although as found in the prior VA examination reports, the Veteran did not meet the full criteria for PTSD. She indicated his functioning was not impaired due to his symptoms. She further noted the March 2010 examination report found his irritability was due to his circumstances at the time and his emotional detachment was consistent with his upbringing.

After a careful review of the evidence of record, the Board finds that service connection for PTSD is warranted. Different providers have offered conflicting opinions as to whether the Veteran had PTSD due to his service. Overall, the Board can identify no compelling reason to find the negative opinions more probative than the positive opinions. Each provider appeared to have considered substantially the same facts, which led them to reach different conclusions. This disagreement must be considered a professional difference of opinion between equally qualified medical experts.

Therefore, after resolving reasonable doubt in the Veteran’s favor, the Board finds that he had PTSD as a result of in-service stressors. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Hence, the claim is granted.

2. Service connection for bilateral hearing loss is granted.

Service connection for impaired hearing is subject to 38 C.F.R. § 3.385, which provides that impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent.

The appellant contends that the Veteran’s hearing loss was related to his combat service in Vietnam. The Veteran, during his lifetime, testified that while in Vietnam, he was exposed to gunfire, mortar shells, browning machine guns and helicopters. He stated he never wore hearing protection.

The Board finds the Veteran served in combat and was likely exposed to acoustic trauma while serving in Vietnam, given that such exposure is consistent with the circumstances, conditions and hardships of that service. 38 U.S.C. § 1154(b). The Veteran’s personnel records show he received a bronze star, Korean service medal, combat medal badge and Vietnam service medal. As such, VA must presume the occurrence of the in-service injury.

Additionally, the medical evidence shows that the Veteran has a current diagnosis of bilateral hearing loss for VA purposes under 38 C.F.R. § 3.385. See May 2010 VA examination.

Thus, the sole issue is whether the Veteran’s bilateral hearing loss was related to service.

The May 2010 examiner indicated the Veteran’s hearing loss was not related to service. She stated that based on medical research, noise induced hearing loss occurs immediately and there is no scientific support for delayed onset hearing loss weeks, months or years after exposure. She indicated given the Veteran’s hearing was within normal limits at the time of separation, it is less likely as not that the hearing loss was related to military noise exposure.

At the October 2014 hearing, the Veteran indicated that his hearing gradually worsened between 1948 and 1971 and continued thereafter. He testified that the onset of his hearing loss was in service.

When resolving reasonable doubt in the Veteran’s favor, the Board determines his hearing loss is related to service. While the May 2010 VA examiner opined that the Veteran’s bilateral hearing loss was not due to his service, the Board finds that because the hearing loss was caused by an injury during combat, symptoms of hearing loss are observable by a lay person. Further, the May 2010 examiner did not specifically address the Veteran’s lengthy service and conceded exposure to hazardous noise. Thus, overall, the Board finds the question of whether the Veteran’s hearing loss had its onset during service and has continued since, is in equipoise. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).

Therefore, in light of his in-service combat-related acoustic trauma, the credible history of bilateral hearing loss in and since service, and the diagnosis of bilateral hearing loss, the Board finds that service connection for bilateral hearing loss is warranted. See 38 U.S.C. 5107; 38 C.F.R. §§ 3.102.

3. Service connection for a left knee disorder.

The appellant contends the Veteran injured his
to hazardous noise. Thus, overall, the Board finds the question of whether the Veteran’s hearing loss had its onset during service and has continued since, is in equipoise. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).

3. Service connection for a left knee disorder.

The appellant contends the Veteran injured his left knee during service and the disorder continued thereafter. The Veteran underwent a June 2009 left knee unicompartmental arthroplasty and osteoarthritis was indicated.

The Veteran’s service treatment records are silent for complaints or treatment related to a left knee injury, including his April 1971 separation examination and report of medical history.

Following service, an August 2004 private treatment record indicated the Veteran had presumed left knee degenerative joint disease (DJD). The Veteran testified that he fell into a drainage ditch during his service in Vietnam and twisted his left knee. He indicated after falling in the ditch, he was unable to receive treatment for his knee as he was in a combat setting. He reported he continued to experience symptoms following service. During the hearing, the appellant reported she had known the Veteran since 1977 and he always had problems with his left knee.

A May 2013 medical questionnaire was submitted in which the examiner diagnosed the Veteran with left knee joint pain and muscle weakness. He indicated the Veteran had mild small osteophytes.

In October 2018, the claim came before the Board and it determined an expert medical opinion from a Veterans Health Administration (VHA) physician was required. An October 2018 opinion was obtained from an orthopedic surgeon at a VA Medical Center; thus, a medical professional with great expertise in the relevant area. The Board notes the opinion was sent to the appellant and her representative in January 2019. After being returned as undeliverable, the appellant’s address was confirmed, and the decision was reissued to her in April 2019 and she was given 60 more days to submit further evidence or argument. See 38 C.F.R. §§ 20.901, 20.903. To date, no additional evidence or argument has been submitted from the appellant, although a March 2019 appellate brief was submitted and is addressed below.

The October 2018 physician concluded the Veteran’s left knee disorder less likely than not had its onset during or was otherwise related to service. He noted the Veteran’s contention of being injured during his service in Vietnam, including having fallen into a drainage ditch. He opined the Veteran likely did sustain an injury to his left knee while in Vietnam and it is understandable why he did not report the injury during a combat situation. He stated the Veteran could have sprained his knee with the fall, however, if he had a significant knee injury like a torn meniscus or significant ligamentous injury he would have reported it after he was out of the combat situation. The reviewer indicated the Veteran’s discharge examination gave no history of a knee injury and no records were seen for a knee problem until he was 74 years old and some 33 years following service. Therefore, he concluded the Veteran’s left knee problem was most likely degenerative in nature and his osteoarthritis was not caused by his military service.

The Board determines that the Veteran’s left knee disorder did not have its onset during service and is not otherwise related. The Board acknowledges the Veteran’s consistent contentions related to being hurt during his service in Vietnam, including falling into a drainage ditch and not seeking treatment due to a combat situation. However, the most probative evidence of record is the October 2018 VHA expert medical opinion. That opinion was provided by an orthopedic surgeon whose opinion was unequivocally stated, consistent with the evidence of record, and supported by a detailed rationale. See Nieves-Rodriguez, 22 Vet. App. at 295 (2008) (“[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”).

In a March 2019 brief, the appellant’s representative challenged the adequacy of the October 2018 medical opinion. The representative argued that the physician noted the Veteran would have reported any serious knee injury and that he did not know what diagnosis applied. The representative noted many injuries can start small but worsen over time. The Board acknowledges the representative’s statements but finds the examiner discussed that the Veteran would not have been able to report a knee injury during a combat situation and that he would have likely reported a more severe knee injury before the 2004 onset of treatment. Further, the reviewer addressed the diagnoses found in the record of presumed DJD, as well as left knee joint pain and muscle weakness. Based on an overall reading, it is clear that the examiner found the Veteran’s injury during service to not have been of sufficient severity to cause the eventual diagnosis. This opinion is cogent and compelling as it establishes the medical basis for why the Veteran’s in-service injury could not have been a precursor to or led to the eventual diagnosis. It therefore heightens the strength of the opinion instead of weakening it. See Kahana v. Shinseki, 24 Vet. App. 428 (2011).

The representative brief also argued that there are too many inconsistencies, gaps, and other weaknesses in the STRs to discount the credibility of the Veteran’s statements that he had ongoing symptoms after the initial injury. In further support of the claim, the appellant asserted that she knew the Veteran since 1977 and that he always experienced left knee problems. The Veteran and the appellant as lay persons are competent to report such experiences and observations as first-hand witnesses. However, the occurrence of the in-service symptoms and symptoms is not actually at issue here.

Moreover, it is common knowledge that a traumatic injury can eventual lead to arthritis in a joint. But, in this particular case, the VA medical expert established the medical basis for why the Veteran’s particular injury during service (and subsequent symptoms) were not of sufficient severity to be the etiology of his left knee DJD. The Veteran and appellant lack the requisite expertise to make such distinctions, which are not within the common knowledge of a lay person or otherwise within the competence of a non-medical expert. See Fountain, 27 Vet. App. at 274-75; Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). Therefore, the Veteran and appellant’s statements as to the etiology of his left knee arthritis are not sufficiently probative to increase the likelihood of a nexus to service.

In sum, based on the evidence of record, and particularly the probative expert medical opinion, the Board finds that the Veteran’s left knee disorder did not have its onset during service and is not otherwise related to service. The preponderance of the evidence is against the claim, and thus, service connection for a left knee disorder is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

REASONS FOR REMAND

1. Service connection for Parkinson’s disease

This issue must be remanded for a new medical opinion.

The appellant contends the Veteran had a diagnosis of Parkinson’s disease during his lifetime and that the disease was related to his exposure to Agent Orange.

The Veteran had service in Vietnam and thus, his exposure to Agent Orange in service is established. The material questions of fact central to the outcome of this claim are (a) whether the Veteran had a diagnosis of Parkinson’s disease during his lifetime or, if not, (b) whether his diagnosis was due to Agent Orange even if the diagnosis not on the list of presumptive conditions.

At present, there is some conflicting evidence as to the first question, but overall the evidence indicates that the Veteran did not have Parkinson’s disease during his lifetime. Nonetheless, this same evidence indicates a Parkinson-like condition.

With this in mind, the Board observes that the National Academy of Sciences, Engineering, and Medicine (NAS) Health and Medicine Division, in the Veterans and Agent Orange: Update 11 (2018) (herein after “2018 NAS Update”), concluded that:

[T]he finding for [Parkinson’s disease] should be interpreted by VA to include all diseases with Parkinson-like symptoms unless those symptoms can be definitively shown to be secondary to an external agent other than the herbicides sprayed in Vietnam.

On the basis of the
some conflicting evidence as to the first question, but overall the evidence indicates that the Veteran did not have Parkinson’s disease during his lifetime. Nonetheless, this same evidence indicates a Parkinson-like condition.

On the basis of the lack of new evidence reviewed here supporting or refuting an association with [Parkinson’s disease], and given the evidence presented in previous [VA] reports, the committee maintains the conclusion that there is limited or suggestive evidence of an association between exposure to [Agent Orange] and [Parkinson’s disease], including Parkinson-like conditions such as Parkinsonism, in the setting of dementia, multiple system atrophy, and progressive supranuclear palsy.

This indicates to the Board that there may be a potential nexus between the Veteran’s Agent Orange exposure and his condition. The Board cannot make a fully-informed decision on the issue because no VA examiner has opined whether the Veteran’s condition, even if not conforming to a Parkinson’s disease diagnosis, is related to his Agent Orange exposure during service.

2. Service connection for the cause of the Veteran’s death.

This issue is likewise remanded for a VA medical opinion.

The Veteran died in December 2014. His death certificate lists the immediate cause of death as cerebrovascular accident and the contributory causes of death as dementia and hypertension. Herein above, the Board granted service connection for PTSD and bilateral hearing loss, but neither of those diagnoses was listed on the death certificate.

The appellant contends that the Veteran’s service-connected disabilities substantially contributed to the death of the Veteran.

The material questions of fact are (a) whether either service-connected disability caused or contributed to the Veteran’s death even though not listed on the death certificate or (b) whether any of the medical conditions listed on the death certificate were of service origin.

With regard to the first question, a VA opinion was obtained in July 2018. At present, the Board finds no basis to undertake any further development on the question in light of the examiner’s opinion.

With regard to the second question, there is some further information that might indicate a nexus.

Specifically, the 2018 NAS Update (discussed herein above) upgraded hypertension from its previous classification in the category of “limited or suggestive” evidence of an association to Agent Orange to the category of “sufficient” evidence of an association. According to NAS, “[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. It also maintained its prior conclusion that there was “limited or suggestive evidence of association” because cerebrovascular disease and stroke and Agent Orange exposure.

A medical opinion is needed to more directly address whether the Veteran’s hypertension and/or cerebrovascular accident, in light of the NAS Update’s findings, were related to his Agent Orange exposure.

Likewise, the Board is remanding the claim of service connection for Parkinson’s disease. As the outcome of that claim may impact the cause of death claim, the issues are inextricably intertwined.

The matters are REMANDED for the following action:

1. Obtain a VA opinion from a qualified specialist regarding the claimed Parkinson’s disease.

The examiner is asked to address each of the following:

What was the Veteran’s diagnosis regarding his Parkinson-like condition?

Whether it is at least as likely as not (i.e., is it at least equally probable) that the diagnosis was related to the Veteran’s confirmed Agent Orange exposure during service in Vietnam?

In answering question (b), the examiner is asked to disregard whether the disorder is one for which a “presumption” is established and, instead, to answer whether the medical condition is a result of Agent Orange exposure even though it is not on the list of “presumptive” diseases. The examiner should address the Veterans and Agent Orange: Update 11 (2018), where the National Academies of Sciences, Engineering and Medicine (NAS), found limited or suggestive evidence of an association between exposure to Agent Orange and Parkinson’s disease, including Parkinson-like conditions such as Parkinsonism.

2. Obtain a VA opinion from a qualified specialist regarding the cause of the Veteran’s death.

The examiner is asked to address each of the following:

Whether the cerebrovascular accident and/or hypertension were at least as likely as not related to an in-service injury, event, or disease,
and, instead, to answer whether the medical condition is a result of Agent Orange exposure even though it is not on the list of “presumptive” diseases. The examiner should address the Veterans and Agent Orange: Update 11 (2018), where the National Academies of Sciences, Engineering and Medicine (NAS), found limited or suggestive evidence of an association between exposure to Agent Orange and Parkinson’s disease, including Parkinson-like conditions such as Parkinsonism.

2. Obtain a VA opinion from a qualified specialist regarding the cause of the Veteran’s death.

The examiner is asked to address each of the following:

Whether the cerebrovascular accident and/or hypertension were at least as likely as not related to an in-service injury, event, or disease, including the Veteran’s presumed Agent Orange exposure.

In answering this question, the examiner is asked to disregard whether the disorder is one for which a “presumption” is established and, instead, to answer whether his hypertension is a result of Agent Orange exposure even though it is not on the list of “presumptive” diseases.

The examiner should consider the Veterans and Agent Orange Update 11 (2018), where the National Academies of Sciences, Engineering and Medicine (NAS), upgraded hypertension from its previous classification in the category of “limited or suggestive” evidence of an association to the category of “sufficient” evidence of an association. According to NAS, “[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. This report also identified “limited or suggestive evidence of association that cerebrovascular disease and stroke are associated with exposure to” Agent Orange.

C. BOSELY

Acting Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board B. Isaacs, 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.

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