Citation Nr: 1322649 Decision Date: 07/16/13 Archive Date: 07/24/13 DOCKET NO. 09-09 165 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to service connection for atypical Parkinson's disease. REPRESENTATION Appellant represented by: Wisconsin Department of Veterans Affairs ATTORNEY FOR THE BOARD M. Hannan, Counsel INTRODUCTION The Veteran was a member of the United States Army Reserve from January 1994 to June 2005, with periods of active duty for training and inactive duty training; he also served on active duty from August 1999 to March 2000, and from January 2002 to August 2002. This case originally came before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision issued by the Regional Office (RO) of the Department of Veterans Affairs (VA) in Milwaukee, Wisconsin. The appeal is remanded to the RO via the Appeals Management Center in Washington, DC. REMAND The RO has associated VA treatment records for the Veteran with the claims file. However, review of the records now in the claims file reveals that these records are incomplete. In particular, an April 2008 medicine clinic staff note indicates that the Veteran was requested to provide all private neurology records as none of them were included in his VA medical record. A subsequent July 2008 note states that documents received from an outside source were scanned and stored in "Vista Imaging" but these records have not been included in the evidence of record. On remand, all outstanding VA treatment records should be associated with the claims file. In January 2011, the Board remanded the Veteran's claims for further development. Specifically, the Board asked for a medical opinion as to the onset date of the claimed hypertension, to include a discussion of whether the claimed hypertension had been aggravated by any service-connected disability or treatment thereof. The requested examination took place in March 2012. The VA examiner concluded that the Veteran did not meet the criteria for a diagnosis of hypertension and thus, did not address the questions of onset date or aggravation by service-connected disability. However, review of the medical evidence of record reveals that hypertension was diagnosed at a VA facility in April 2008 and subsequent thereto, that medication to treat hypertension was prescribed, and there were blood pressure readings of 144/97 and 156/98 in the summer of 2008. In addition, the Veteran's private medical records indicate a blood pressure reading of 142/100 in December 2007, and that hypertension was found in March 2008. None of these facts were addressed in the March 2012 medical opinion wherein the examiner found that the Veteran did not have a current or past diagnosis of hypertension. The January 2011 Board remand also directed that a medical opinion regarding whether there was an etiologic relationship between exposure to permethrin and Parkinson's disease be obtained. That medical opinion was rendered in March 2012. Review of the opinion indicates that the VA examiner did not specifically address the Veteran's statements, which were corroborated by his commanding officer, that his uniform was soaked in permethrin and that he wore the uniform while it was still damp. In addition, it is unclear whether or not the examiner reviewed the private neurologist records contained in "Vista Imaging." See Shipwash v. Brown, 8 Vet. App. 218, 222 (1995); Flash v. Brown, 8 Vet. App. 332, 339-340 (1995) (regarding the duty of VA to provide medical examinations conducted by medical professionals with full access to and review of veteran's claims folder). Thus, the evidence before the Board still does not include adequate medical opinions as to whether or not there is any etiological relationship between the Veteran's hypertension or neurological disorder and any incident of his military service. "Once VA undertakes the effort to provide an examination, it must provide an adequate one or, at a minimum, notify the veteran why one will not or cannot be provided." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). "Without a medical opinion that clearly addresses the relevant facts and medical science, the Board is left to rely on its own lay opinion, which it is forbidden from doing." Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007). Consequently, in order to satisfy VA's duty to assist, the Board finds that another remand is necessary in order to obtain adequate medical opinions. 38 U.S.C.A. §§ 5107(a), 5103A (West 2002); 38 C.F.R. § 3.159 (2012). Accordingly, the case is remanded for the following action: 1. The RO must contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claims. Based on his response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. Regardless of his response, all VA treatment records, to include "Vista Imaging" records must be associated with the evidence of record. All attempts to secure this evidence must be documented in the claims file by the RO. If, after making reasonable efforts to obtain named records the RO is unable to secure same, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that he is ultimately responsible for providing the evidence. The Veteran and his representative must then be given an opportunity to respond. 2. After completing any additional notification and/or development action deemed warranted by the record, arrange for a review of the Veteran's claims file by an appropriate specialist, such as an internist or a cardiologist, in light of the questions of causation presented on the issue of entitlement to service connection for hypertension. The physician is to address the history of the nature and extent of the Veteran's hypertension. The physician is to determine whether any currently shown or previously diagnosed hypertension is related to the Veteran's military service or to a service-connected disability. The claims file, all records on Virtual VA, and all other VA electronic records must be made available to the reviewer, and the reviewer must specify in the report what records were reviewed. The reviewer must specify the dates encompassed by the Virtual VA and other VA electronic records that were reviewed. If the physician determines that an examination is needed before the requested opinion can be rendered, schedule the Veteran for such an examination. The physician must consider all blood pressure readings in the Veteran's service medical records, and comment on the clinical significance of, and treatment for, any atypical findings, to include whether they represented a normal variant. The physician must identify the Veteran's various risk factors for the development of hypertension. Based on the findings of the review of the medical evidence of record, as well as the Veteran's statements, the physician must render an opinion concerning: (a) When was the current and/or previously diagnosed hypertension initially manifested? (b) Were there any signs or symptoms of hypertension noted in service or within one year of active duty service separation for the service periods of August 1999 to April 2000, and January 2002 to August 2002, which were the first manifestations of the Veteran's current and/or previously diagnosed hypertension? (c) Has the Veteran's current and/or previously diagnosed hypertension been aggravated to any degree by a service-connected disability, to include any prescription medication prescribed for treatment thereof? A complete rationale for all requested opinions must be provided. If the physician cannot provide the requested opinion without resorting to speculation, it must be so stated, and the physician must provide the reasons why an opinion would require speculation. The physician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the physician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular physician. The report prepared must be typed. 3. After completing any additional notification and/or development action deemed warranted by the record, arrange for a review of the Veteran's claims file by an appropriate specialist, such as a pathologist or a neurologist, in light of the questions of causation presented on the issue of entitlement to service connection for Parkinson's disease. The physician is to address the history of the nature and extent of the Veteran's Parkinson's disease. The physician is to determine whether the Veteran's Parkinson's disease is causally related to the Veteran's military service or to a service-connected disability. The physician must identify the Veteran's various risk factors for the development of Parkinson's disease. The claims file, all records on Virtual VA, and all other VA electronic records must be made available to the physician, and the physician must specify in the report what records were reviewed. The physician must specify the dates encompassed by the Virtual VA and other VA electronic records that were reviewed. If the physician determines that an examination is needed before the requested opinion can be rendered, schedule the Veteran for such an examination. Based on the findings of the review of the medical evidence in the claims files, the physician must render an opinion concerning: (a) When was Parkinson's disease initially manifested? (b) Were there any signs or symptoms noted in service or within one year of service separation for the active duty service periods of August 1999 to April 2000, and January 2002 to August 2002, which were the first manifestations of the Veteran's current Parkinson's disease? (c) In general, is there any etiological relationship between permethrin exposure and neurological disorders such as Parkinson's disease? In particular, is there any etiologic connection in cases such as this where clothing still damp from a permethrin soak was worn by a person? Discuss with reference to the current medical/scientific literature. (d) Has the Veteran's current Parkinson's disease been aggravated by a service-connected disability, to include any prescription medication prescribed for treatment thereof? A complete rationale for all requested opinions must be provided. If the physician cannot provide the requested opinion without resorting to speculation, it must be so stated, and the physician must provide the reasons why an opinion would require speculation. The physician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the physician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular physician. The report prepared must be typed. 4. The evidence of record must be reviewed to ensure that all development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. Specific attention is directed to the medical reports. If either report does not include fully detailed descriptions of all pathology or adequate responses to the specific opinions requested, the report must be returned to the providing physician for corrective action. See 38 C.F.R. § 4.2 (2012). 5. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken above, the claims on appeal must be readjudicated. If either issue on appeal remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, the Veteran may present additional evidence or argument while the case is in remand status. Kutscherousky v. West, 12 Vet. App. 369 (1999). _________________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252, 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).