Citation Nr: 1330925 Decision Date: 09/26/13 Archive Date: 09/30/13 DOCKET NO. 07-12 665 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to a rating in excess of 20 percent for diabetes mellitus. 2. Entitlement to an initial rating in excess of 10 percent for hypertension. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD M. Riley, Counsel INTRODUCTION The Veteran served on active duty from August 1966 to August 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal from a December 2005 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, which, in pertinent part, continued a 20 percent evaluation for diabetes mellitus and awarded service connection for hypertension with an initial 10 percent evaluation effective August 17, 2005. The December 2005 rating decision also decreased the evaluation assigned for prostate adenocarcinoma status post radical retropubic prostatectomy from 100 percent to 60 percent effective March 1, 2006. The Veteran also perfected an appeal as to this issue. In an October 2010 rating decision, the 100 percent evaluation was reinstated effective March 1, 2006. This action constitutes a full grant of the disability benefits on appeal, and the claim for entitlement to an increased rating for prostate adenocarcinoma is not before the Board. In a May 2012 statement, the Veteran raised additional claims for compensation including whether new and material evidence has been received to reopen claims for entitlement to service connection for a cervical spine disability and bilateral hearing loss and original claims for service connection for disorders of the back, bilateral hips, bilateral knees, and bilateral ankles, and for vertigo, chronic fatigue, a cognitive disorder, and headaches. These issues have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them and they are referred to the AOJ for appropriate action. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Board finds that additional development is necessary before a decision may be rendered in this case. First, the Board finds that efforts must be made to obtain additional records of VA and private treatment. The Veteran's virtual claims file currently contains records from the VA Corpus Christi Outpatient Clinic (OPC) dated through February 2012. The Veteran testified in June 2012 that he continued to receive treatment for diabetes mellitus and hypertension at the VA facility and efforts must be made to obtain his most recent VA treatment records. See Bell v. Derwinski, 2 Vet. App. 611 (1992). Additionally, while the Veteran testified that he received all his treatment through the VA, his wife testified that she occasionally consulted their family physician regarding the Veteran's diabetes. She specifically spoke of an incident of hypoglycemia that occurred in approximately January 2012 when she contacted the Veteran's family doctor, identified as Dr. J.M. The record currently contains some records from this physician, but none dated more recently than March 2005. Furthermore, the record contains December 2005 prescription orders for insulin from a private endocrinologist, though treatment records from this provider are not included in the claims file. VA has a duty to obtain relevant records of treatment reported by private physicians, and records from the private doctors and facilities identified by the Veteran and his wife must be obtained. Massey v. Brown, 7 Vet. App. 204 (1994). The Board also finds that VA examinations are necessary to determine the current severity of the service-connected diabetes mellitus and hypertension. During the January 2012 video hearing, the Veteran testified that his disabilities had worsened since the most recent VA examinations in January 2010. He specifically reported that his disabilities no longer responded to medication and manifested increased blood sugar and blood pressure measurements. The Veteran is entitled to a new VA examination where there is evidence that the condition has worsened since the last examination. Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). The Veteran is also competent to provide an opinion that his disability has worsened. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The Veteran is hereby notified that it is his responsibility to report for any scheduled examination and to cooperate in the development of the case, and that the consequences of failing to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158 and 3.655 (2012). Accordingly, the case is REMANDED for the following action: 1. Obtain records of treatment from the Corpus Christi VA OPC (and any other appropriate VA facilities) for the period beginning February 2012. 2. Provide the Veteran with medical release forms and ask that he execute them to allow VA to obtain records of private treatment from any private health care providers who have treated the service-connected diabetes mellitus or hypertension, to include his family doctor, Dr. J.M. with Corpus Christi Family Medicine Center, and Dr. J.C., a doctor of endocrinology and internal medicine. 3. If appropriate medical release forms are received, obtain records of treatment from the private physicians identified by the Veteran. All efforts to obtain these records must be documented in the claims file. If unsuccessful in obtaining this evidence, inform the Veteran and his representative and request them to provide the outstanding evidence. Copies of all records must be added to the virtual or paper claims file. 4. Schedule the Veteran for a VA examination(s) to determine the current severity of all manifestations of his service-connected diabetes mellitus and hypertension. The claims file must be provided to the examiner and reviewed in conjunction with the examination. The examination report must contain the following findings: a) Determine the severity of the Veteran's diabetes mellitus, to include whether it requires/manifests any of the following: insulin, a restricted diet, regulation of activities, episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year, or twice a month visits to a diabetic care provider. b) Determine the Veteran's diastolic pressure as well as his systolic pressure and indicate whether diastolic pressure is predominantly 110 or more and whether systolic pressure is predominantly 200 or more. A complete rationale (i.e. basis) is required for all provided medical opinions. 5. Readjudicate the claims on appeal. If the benefits sought on appeal are not fully granted, issue a SSOC before returning the case to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matters 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 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). _________________________________________________ D. VAN WAMBEKE 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).