Citation Nr: 0943889 Decision Date: 11/18/09 Archive Date: 11/25/09 DOCKET NO. 06-28 135 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to renal cysts. 2. Entitlement to service connection for renal cysts, to include as secondary to hypertension. 3. Entitlement to service connection for lesions on the liver, also characterized as hepatic abnormalities. REPRESENTATION Veteran represented by: Roger L. Wolfe, Jr., Attorney at law WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Helena M. Walker, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1955 to July 1958. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland, which denied the benefit sought on appeal. The Board notes that the three issues listed on the title page of this decision were originally adjudicated as one issue. The Board notes that they are more properly characterized as three separate claims for service connection. In September 2009, the Veteran appeared and testified at a Central Office hearing. The transcript is of record. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2009). 38 U.S.C.A. § 7107(a)(2) (West 2002). During his September 2009 hearing, the Veteran raised the issue of entitlement to service connection for arteriosclerotic cardiovascular disease, to include as secondary to any service-connected disability. This issue is referred to the RO for any appropriate action. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. REMAND In light of the VCAA, further evidentiary development is necessary. The Veteran essentially contends that his hypertension, renal cysts, and liver lesions are related to service or a service- connected disability. The Veteran's service treatment records (STRs) are unavailable, and there are no clinical records from that time period associated with the claims file. The Veteran testified that the onset of his high blood pressure was in service, and he has been treated for it since service. He reported a history of recurrent headaches and nosebleeds. He advised that he declined to extend his service due to his high blood pressure, and upon separation from service was told to seek treatment for his high blood pressure. The Veteran reported that he indeed sought immediate post-service treatment for his high blood pressure, but he was unable to obtain those records as the treating physicians have since passed away. The Board recognizes that it has a heightened duty to provide its reasons and bases in rendering a decision when a veteran's service treatment records have been lost or destroyed. See Washington v. Nicholson, 19 Vet. App. 362, 371 (2005). Post-service treatment records, dated in the 2000s reflect treatment for high blood pressure with a diagnosis of hypertension. The Veteran's wife has reported that she recalled the Veteran first receiving treatment for high blood pressure in service and has been treated since. Following CT scans of the abdomen and pelvis in December 1998, the Veteran was found to have probable hemangiomas of the liver and multiple renal cysts. In a December 2004 private treatment record, he was noted to have renal insufficiency. The treating physician indicated that his "renal insufficiency [was] probably more related to hypertensive vascular disease and aging than anything else." In March 2009, the Veteran underwent an examination by Craig N. Bash, M.D. Upon review of the clinical records, lay statements, other medical opinions, and medical literature review, Dr. Bash indicated that the Veteran's "high blood pressure is due to his service time high blood pressure[,] which is likely due to his renal cysts." In reaching this opinion, Dr. Bash noted that the Veteran presented with recurrent headaches and nosebleeds during service, and they resolved with treatment with anti-hypertensive medication. Dr. Bash also supported his opinion in that the Veteran was on continuous treatment for his cyst/angiotension induced hypertension. Dr. Bash indicated that the Veteran's diagnosis of renal cysts is consistent with a finding of hypertension as renal cysts induce hypertension due to increased angiotension. Dr. Bash also indicated that although the Veteran's STRs are not available, the Veteran's testimony and medical history is consistent with experiencing hypertension in service. Upon review of the evidence of record, the Board finds that further evidentiary development is necessary to clarify the opinion from Dr. Bash. The Board finds that there is inconsistent medical evidence of record and further examination with an opinion is necessary. The Board points to the December 2004 private treatment record finding that renal insufficiency was due to hypertensive vascular disease and aging. This contradicts Dr. Bash's March 2009 opinion that the Veteran's hypertension was caused by his renal cysts. The Board recognizes that Dr. Bash also found that the Veteran's high blood pressure had its onset in service, but then concluded that the Veteran's hypertension is secondary to his renal cysts. The clinical evidence of record shows a finding of renal cysts as early as December 1998, and the private treatment records show treatment for high blood pressure in the early 2000s. Also, Dr. Bash did not indicate whether any renal cysts were due to service, only that high blood pressure had its onset in service. Dr. Bash primarily found that the Veteran's hypertension was due to renal cysts, and this was supported by the above-mentioned rationale. It appears that the clinical evidence of record is conflicting and unclear, thus, the Board finds that a remand is necessary for a VA examination to be scheduled to determine whether any currently diagnosed hypertension, renal disease, and liver lesions are attributable to the Veteran's service or a service-connected disability. Also, during his September 2009 hearing, the Veteran and his representative requested a copy of the hearing transcript. Of date, the Veteran has not been provided a copy. Thus, upon remand, a copy of the transcript should be sent to the Veteran and his representative. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2009). Expedited handling is requested.) 1. Send the Veteran and his representative a copy of the September 2009 hearing transcript. 2. Schedule the Veteran for a VA examination with an appropriate specialist to determine the nature and etiology of his claimed hypertension, renal disease, and lesions of the liver. The Veteran's claims folder should be made available to the examiner. The examiner is to perform all necessary clinical testing and render all appropriate diagnoses. The examiner should then render an opinion as to whether it is at least as likely as not that the Veteran's currently diagnosed hypertension, renal disease, and lesions of the liver had their onset in service. If any of the three claimed disabilities is found to be attributable to the Veteran's service, the examiner is asked to opine as to whether such disability caused or aggravated any other of these claimed disabilities. In reaching his or her opinion, the examiner should also address the March 2009 opinion of Dr. Bash. The examiner should provide rationale for all opinions given. If the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation. 3. When the development requested has been completed, the case should be reviewed on the basis of the additional evidence. If the benefits sought are not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case, and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The purpose of this REMAND is to obtain additional evidentiary development and the Board, at this time, does not intimate any opinion as to the merits of the case, either favorable or unfavorable. The Veteran is free to submit any additional evidence and/or argument he desires to have considered in connection with his current appeal. No action is required of the Veteran until he is notified. This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). _________________________________________________ James L. March Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2009).