Citation Nr: 1306183 Decision Date: 02/22/13 Archive Date: 02/27/13 DOCKET NO. 10-15 464 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for diabetes mellitus, type II. 2. Entitlement to service connection for hypertension. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD T. Blake, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1972 to July 1979 and with periods of active duty for training and inactive duty training in the Army Reserve from April 1989 to January 2007. This case comes before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas which, in pertinent part, denied service connection for diabetes mellitus and hypertension. In August 2011, the Veteran testified at a Board hearing held before the undersigned Acting Veterans Law Judge in Waco, Texas. A copy of the transcript is of record. The Veteran submitted a waiver of initial RO consideration of the new evidence submitted in conjunction with the hearing. 38 C.F.R. § 20.1304(c) (2012). The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. The issue of service connection for hypertension is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. All relevant evidence necessary to decide the Veteran's appeal regarding the issue of service connection for diabetes mellitus, type II, has been obtained. 2. The Veteran did not sustain an injury, disease, or event manifesting in diabetes mellitus, type II, during active service. 3. Diabetes mellitus, type II, symptoms were not chronic in service. 4. Diabetes mellitus, type II, symptoms have not been continuous since separation from service. 5. The Veteran's current diabetes mellitus, type II, is not related to service and did not manifest within one year of separation from active service. CONCLUSION OF LAW The criteria for service connection for diabetes mellitus, type II, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. The Board finds that the VCAA notice requirements have been satisfied by an April 2008 letter. In this letter, VA informed the Veteran that in order to substantiate a claim for service connection, the evidence needed to show he had a current disability, a disease or injury in service, and evidence of a nexus between the post service disability and the disease or injury in service, which was usually shown by medical records and medical opinions. As to informing the Veteran of which information and evidence he was to provide to VA and which information and evidence VA would attempt to obtain on his behalf, VA informed the Veteran it had to obtain any records held by any federal agency. This letter also informed the Veteran that on his behalf VA would make reasonable efforts to obtain records that were not held by a federal agency, such as records from private doctors and hospitals. Finally, the letter told the Veteran that he could obtain private records himself and submit them to VA. The VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection was awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, the April 2008 letter included the type of evidence necessary to establish a disability rating and effective date. Regarding the duty to assist, VA must make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the claim for diabetes mellitus, type II, on appeal, the evidence of record includes the Veteran's service treatment records, VA outpatient treatment records, private treatment records, statements from the Veteran, and August 2011 Board hearing transcript. The Veteran was not afforded a VA examination in connection with this claim, but none is required. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Federal Circuit has addressed the appropriate standard to be applied in determining whether an examination is warranted. In Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) and Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), the Federal Circuit held that while there must be "medically competent" evidence of a current disability, "medically competent" evidence is not required to indicate that the current disability may be associated with service. Colantonio, 606 F.3d at 1382; Waters, 601 F.3d at 1277. On the other hand, a conclusory generalized lay statement suggesting a nexus between a current disability and service would not suffice to meet the standard of subsection (B), as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. Waters, 601 F.3d at 1278-1279. Here, the only evidence of record suggesting a link of record between the claimed disorder and service is the Veteran's own conclusory generalized lay statements, which are unsupported by the competent medical evidence of record. Accordingly, the Board finds that referral for a VA medical examination is not warranted. Significantly, neither the Veteran nor his or representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claim on appeal. The evidence of record provides sufficient information to adequately evaluate the claim, all obtainable evidence identified by the Veteran relative to the claim has been obtained and associated with the claims file, and the Board is not aware of the existence of any additional relevant evidence which was not obtained. Therefore, no further assistance to the Veteran with the development of evidence is required. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A §§ 1110, 1131 (West 2002). When a chronic disease is shown as such in service (or within the presumptive period under 38 C.F.R. § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected unless clearly attributable to intercurrent causes. See 38 C.F.R. § 3.303(b); see also Savage v. Gober, 10 Vet. App. 488, 498 (1997). A "chronic disease in service" requires a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word 'chronic.' Id. When the disease identity is established, there is no requirement of evidentiary showing continuity; however, continuity of symptomatology after discharge is required to support the claim only where the condition noted during service is not, in fact, shown to be chronic or the diagnosis of chronicity may be legitimately questioned. Id. Service connection may also be granted for any disease after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The Board observes that the Veteran has periods of service in the Army Reserve, to include active duty for training and inactive duty training. The term "active military service" includes any period of active duty for training during which the individual concerned was disabled from a disease or injury incurred or aggravated in the line of duty, and any period of inactive duty training during which the individual concerned was disabled from an injury incurred or aggravated in the line of duty. Service connection may also be granted for disability arising from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during inactive duty training. 38 U.S.C.A. § 101(24) ; 38 C.F.R. § 3.6. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as diabetes mellitus, type II, to a degree of 10 (compensable) percent or more within one year of separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67 (1997); Layno v. Brown, 6 Vet. App. 465 (1994); Cartwright v. Derwinski, 2 Vet. App. 24 (1991) (although interest may affect the credibility of testimony, it does not affect competency to testify). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. at 465. The Board is charged with the duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Medical evidence that is speculative, general or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). A physician's statement framed in terms such as "may" or "could" is not probative. See Warren v. Brown, 6 Vet. App. 4, 6 (1993). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Analysis of Service Connection for Diabetes Mellitus, Type II At the August 2011 Board hearing, the Veteran testified that his diabetes mellitus, type II, had its onset while in service in 2000 or 2001, and thus service connection is warranted for this disorder. At the outset, the Board finds that the Veteran has a current disability of diabetes mellitus, type II, as documented in a June 2008 VA outpatient treatment record. Nonetheless, the weight of the evidence demonstrates that the Veteran did not sustain an injury, disease, or event manifesting in diabetes mellitus, type II, during active service, nor were diabetes mellitus, type II, symptoms chronic in service. At the time of entry to service, an August 1972 examination report showed no findings of abnormalities of the endocrine system. On a December 1973 medical history questionnaire, completed by the Veteran in preparation for an X-ray, he reported had been treated for diabetes; however, no further details were noted. Service treatment records and examination reports dated August 1975, March 1978, and July 1979 revealed no findings of abnormalities of the endocrine system or relating to diabetes mellitus. During service in the Army Reserve from 1989 to 2007, treatment records further indicate no complaints of or diagnosis for diabetes mellitus. In fact, the Veteran marked "no" for having or ever having had high or low blood sugar on a January 2005 medical board report of medical history and the January 2005 medical board examination report revealed no pertinent abnormalities regarding this disorder on appeal. Although the Veteran testified at the August 2011 Board hearing that his diabetes was borderline while in service and was full blown in 2000 or 2001, which the Board notes was during his period of service in the Army Reserve, the Board finds that review of the record, as discussed above, do not support the Veteran's contentions of an onset in service. Such evidence shows no in-service injury, disease, or event, or even chronic symptoms of diabetes mellitus, type II, disorder during service. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). The Board finds that the weight of the evidence does not demonstrate that diabetes mellitus, type II, symptoms have been continuous since separation from service. Treatment records immediately following separation from service in July 1979 until entry to service in the Army Reserve in April 1989, are silent as to medical findings or complaints regarding diabetes mellitus. In fact, February 1980 VA examination and August 1988 examination reports documented normal results from clinical evaluation of the endocrine system. Following service in the Army Reserve, VA outpatient treatment records indicate the Veteran was assessed with impaired glucose in September 2007 and the physician noted a plan to follow in six months. Subsequently, the Veteran was diagnosed with diabetes mellitus in March 2008 and the physician noted the Veteran went into full blown diabetes over the last few months, has a history of impaired fasting glucose, and will consider insulin for treatment at a later time. An April 2008 record listed the Veteran has diabetes mellitus, without mention of complication, type II or unspecified type. Approximately two months later, in June 2008, as assessment of diabetes mellitus, type II, was made, and a May 2008 record indicated the Veteran has had diabetes mellitus for one year. The Board further finds that the weight of the evidence demonstrates the Veteran's currently diagnosed diabetes mellitus, type II, is not related to active service. None of the VA outpatient treatment records in the claims file etiologically relates the Veteran's current diagnosis of diabetes mellitus, type II, to service or to any event in service. In addition, as noted above, the first documentation of impaired glucose was in the September 2007 VA outpatient treatment record, then assessments of diabetes mellitus were made in March 2008 and April 2008 VA outpatient treatment records. These first documentations indicate multiple years after separation from service, and the gap of time in the record militates against a finding that the Veteran's diabetes mellitus, type II, had its onset during service. See 38 C.F.R. § 3.303(b); see also Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability). The Board acknowledges the Veteran is competent to report symptoms that he experiences at any time regarding the diabetes mellitus, type II, disorder because this requires personal knowledge as it comes through the use of his senses. See Layno, 6 Vet. App. at 470. He is not, however, competent and with the appropriate medical training and expertise to offer an opinion on a medical matter, including the etiology of his diabetes mellitus, type II. See Bostain v. West, 11 Vet. App. 124, 127 (1998); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). The question of causation, in this case, involves a complex medical issue that the Veteran is not competent to address. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Based on the evidence of record, the weight of the competent evidence demonstrates no relationship between the Veteran's currently diagnosed diabetes mellitus, type II, and his period of active service, including no credible evidence of continuity of symptomatology since service which would serve either as a nexus to service or as the basis for a medical nexus opinion. As a result, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection on a direct basis. Moreover, as discussed above, the evidentiary record shows that the Veteran was not diagnosed with diabetes mellitus, type II, during the first year after active service. Therefore, service connection for diabetes mellitus, type II, on a presumptive basis as a chronic disease is not available in this case. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. For the reasons and bases discussed above, the Board finds that a preponderance of the evidence is against the claim for service connection for diabetes mellitus, type II, and this claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for diabetes mellitus, type II, is denied. REMAND A remand is required in this case to ensure there is a complete record upon which to decide the issue of service connection for hypertension because the claims file does not include a medical opinion addressing whether hypertension is related to service. VA has a duty to make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a); 38 C.F.R. § 3.159(c), (d); Ascherl v. Brown, 4 Vet. App. 371, 377 (1993). Concerning the question of in-service disease, injury, or event, the evidence of record reveals pertinent blood pressure readings during his period of active duty and service in the Army Reserve. Such pertinent readings are as follows: 125 over 100 in May 1979, 146 over 94 in May 1987, 156 over 94 in January 2002, 146 over 92 in May 2002, and 136 over 104, 148 over 104, and 140 over 94 with a notation of "?HTN" in a January 2005 medical board examination report. The Veteran also testified at the August 2011 Board hearing that he had high blood pressure during service, particularly upon returning from Panama and was told the readings were borderline. He was also treated for hypertension while in service with medication, a restricted diet, and frequent checkups. With respect to whether the Veteran's hypertension may be associated with service, the Veteran reported at the Board hearing that the date of onset was during service and he has had symptomatology of persistent or recurrent symptoms of hypertension since separation from service. He reportedly started receiving private treatment immediately after separation from service, and that physician is now deceased. The Veteran continues to seek treatment through a VA facility, form which he is prescribed daily medication. VA outpatient treatment records document the following pertinent blood pressure readings: 141 over 91, 140 over 90, and 130 over 90 in August 2007, 154 over 105 in December 2007, 140 over 90 and 142 over 96 in January 2008, 138 over 90 in February 2008, and 156 over 100, 148 over 108, 138 over 96, and 140 over 90 in March 2008. An April 2008 record noted a diagnosis of hypertension, well controlled with the start of medication. The Board finds this case presents a certain medical question that cannot be answered by the Board and is not addressed by the evidence of record. See McLendon, 20 Vet. App. at 83; Waters, 601 F.3d at 1274; Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Specifically, this question concerns the relationship, if any, between the Veteran's hypertension and active service. This question should be addressed by the appropriately qualified medical professional. See Charles v. Principi, 16 Vet. App. 370 (2002); see also 38 C.F.R. § 3.159(c)(4) (a medical examination or opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim). As a result, the evidence of record presents an inadequate basis to adjudicate the issue of service connection for hypertension. A VA examination with medical nexus opinion would assist in determining the nature and etiology of this claimed disorder on appeal. Additionally, as discussed above, the Veteran asserts that the date of onset for his hypertension was during service, specifically in the Army Reserve. While there is a diagnosed disability during the appeal period and suggestive link to service by a continuity of symptomatology, there remains some question as to whether the in-service diastolic blood pressure readings of 90mm and above in January 2002, May 2002, and January 2005 were during a period of active duty for training (ACDUTRA). Review of the record reflects that the Veteran's dates of active duty for training (ACDUTRA) are not clearly of record. In August 2011, the Veteran submitted a Chronological Statement of Retirement Points, via an AHRC Form 249020E, indicating his periods of service from October 1972 to January 2007. However, service records providing points are not helpful in this regard. Thus, the Board finds that, in order to properly adjudicate the claim on appeal, all periods of ACDUTRA must be verified. Accordingly, the issue of service connection for hypertension is REMANDED for the following actions: 1. Contact all appropriate sources, to include the National Personnel Records Center (NPRC) and the Army Reserves, in order to verify the specific dates of the Veteran's ACDUTRA from April 1989 to January 2007. If necessary, the Veteran should be requested to provide any assistance. All verified dates of service and all responses received should be documented and associated with the claims file. All outstanding service personnel records should also be obtained and associated with the claims file. 2. After completion of the requested development as outlined above, schedule the Veteran for an appropriate VA examination to determine whether there is a nexus between active military service and the currently diagnosed hypertension. The relevant medical records should be made available to the examiner for review in conjunction with the examination, and the examination report should reflect that such review has been accomplished. Any necessary testing should be conducted and any pertinent findings should be documented in the examination report. The VA examiner) must provide an opinion as to whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent) that hypertension had its origin in service or is in any way related to the Veteran's active service, to include his periods of documented ACDUTRA. A rationale should be given for all opinions and conclusions expressed and should not be solely based on the absence of treatment records during or after service. If an opinion cannot be rendered without resorting to speculation, the VA physician should explain why it would be speculative to respond. 3. Thereafter, the issue of service connection for hypertension should be readjudicated. If the benefit sought on appeal is not granted, the Veteran and his representative should be provided with a supplemental statement of the case (SSOC) and afforded the appropriate time period within which to respond thereto. The Veteran and representative have the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of the claim. See 38 C.F.R. § 3.655 (2012). This claim must be afforded expeditious treatment. The law requires that all claims 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. 2012). ________________________________________________ T. D. JONES Acting 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) (2012). Department of Veterans Affairs