Citation Nr: 1312430 Decision Date: 04/15/13 Archive Date: 05/02/13 DOCKET NO. 01-08 519A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to service connection for hypertension, to include on a secondary basis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Catherine Cykowski, Counsel INTRODUCTION The Veteran had active duty service from April 1964 to April 1968. This matter is before the Board of Veterans' Appeals (Board) on appeal from a September 2000 rating decision by the Department of Veterans' Affairs (VA) Regional Office (RO) in Los Angeles, California which, in pertinent part, denied the Veteran's request to reopen his claim of entitlement to service connection for hypertension. The Veteran testified at a videoconference hearing before the undersigned Acting Veterans Law Judge in August 2006. A hearing transcript has been associated with the claims file. In August 2012, the Board reopened the Veteran's claim and remanded the issue of entitlement to service connection for hypertension for additional development. 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 appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action on his part is required. REMAND In its August 2012 remand, the Board instructed the RO or the AMC (in pertinent part) to arrange for the Veteran to be examined by a physician with the appropriate expertise to determine the etiology of the Veteran's hypertension, to include whether his hypertension is etiologically related to his service or was caused or permanently worsened by service-connected disability. The examiner was to review the Veteran's claims file, including an April 1965 STR, which notes a history of high blood pressure and a blood pressure reading of 112/96. The Board points out that for VA purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 mm. (millimeters of mercury) or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90 mm. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). The Veteran was provided with a VA examination in November 2012 conducted by a nurse practitioner, who did not address all the relevant medical findings of record. The medical opinion only some pertinent blood pressure readings but did not address all pertinent blood pressure readings, including the reading of 112/96 obtained in April 1965. Under applicable regulation, "if [an examination] report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes." 38 C.F.R. § 4.2. See also Littke v. Derwinski, 1 Vet. App. 90, 92 (1990); Green v. Derwinski, 1 Vet. App. 121 (1991).) Moreover, a physician did not review or sign the examination report. According to M21-1MR, Part III, Subpart IV, Chapter 3, Section D 18(a), an examination report must be reviewed and signed by a medical doctor when an examination has been conducted by a physician assistant or nurse practitioner. In addition, because the August 2012 remand order indicated that a physician should review the Veteran's claims file and render the opinion, it was in violation of the prior remand for the examination to be scheduled with a nurse practitioner. See Stegall v. West, 11 Vet. App. 268, 271 (1998). For all these reasons, the Board finds that the August 2012 VA examination report is inadequate for adjudication purposes and another medical opinion should be obtained. Accordingly, the case is REMANDED for the following action: 1. Obtain a medical opinion from a physician, either by examination of the Veteran or solely by a review of the claims file (the determination to be made based on the judgment of the physician), as to the etiology of any current or recent hypertension. The Veteran's claims file must be reviewed by the physician in conjunction with this request. The physician is requested to provide opinions as to the following questions: a. Is it at least as likely as not (a 50 percent or greater probability) that any hypertension present during the period of this claim is etiologically related to the Veteran's active service, to include the blood pressure reading of 112/96 noted in an April 1965 STR? b. Is it at least as likely as not (a 50 percent or greater probability) that any hypertension present during the appeal period of this claim was caused of permanently worsened by a service-connected disability? The physician should consider the Veteran's account of his symptoms during and after service to be credible for the purposes of the opinion. If the physician concludes that the Veteran is an unreliable historian, the examiner should provide the reasons for such a conclusion. A rationale for each opinion must be provided. If the physician cannot provide an opinion without resort to speculation, the examiner should state why it is not possible to provide an opinion. 2. The Veteran should be given adequate notice of the date and place of any requested examination. A copy of all notifications, including the address where the notice was sent, must be associated with the claims files if the Veteran fails to report for the examination. The Veteran is advised that failure to report for a scheduled VA examination without good cause may have an adverse effect on his claim. 3. Following the completion of the requested actions, the RO/AMC should again review the record and readjudicate the service connection claim. If the benefit sought on appeal remains denied, the RO/AMC should furnish the Veteran and his representative a supplemental statement of the case and afford them an opportunity to respond. Thereafter, the case should be returned to the Board. By this remand, the Board intimates no opinion as to any final outcome warranted. The appellant has the right to submit additional evidence and argument on the matter that the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). _________________________________________________ K. R. FLETCHER 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).