Citation Nr: 1337974 Decision Date: 11/20/13 Archive Date: 12/06/13 DOCKET NO. 10-21 725 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for hypertension, to include as secondary to service connected diabetes mellitus type II. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Sara Kravitz, Associate Counsel INTRODUCTION The Veteran served from May 1969 to December 1970. This case comes before the Board of Veterans' Appeals (the Board) on appeal from a May 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee denying direct service connection for hypertension. In an August 2009 rating decision the RO denied entitlement to service connection for hypertension, to include as secondary to service connected diabetes mellitus type II. The Board notes that, in addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claims. The Board has reviewed the documents in both the paper claims file and the electronic claims file in rendering this decision. 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 this case, the Veteran essentially contends he has hypertension, secondary to his service connected disability of diabetes mellitus type II. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A review of the claims file reflects that a remand for another opinion regarding the etiology of the Veteran's hypertension is necessary prior to analyzing the claim on the merits. The appeal must be remanded to the RO/AMC in compliance with VA's duty to assist and to provide an adequate medical examination. The Veteran was afforded a compensation and pension examination for peripheral nerves in May 2009. The examiner found that the Veteran's hypertension was not caused by his diabetes mellitus because the Veteran's hypertension was diagnosed simultaneously with his diabetes. The examiner further stated that over time, the Veteran's diabetes and hypertension combined may lead to the development of heart disease, but at the time of the examination the Veteran had no symptoms of coronary artery disease. In July 2009, while receiving treatment at a VA medical center, the attending physician noted the Veteran's diabetes and hypertension were "interrelated," along with his obesity. The Veteran was afforded a diabetes VA compensation and pension examination in June 2010. The examiner gave the Veteran a diagnosis of essential hypertension and stated that the hypertension was not a complication of diabetes, because it was diagnosed prior to the diabetes. He also stated that the Veteran's hypertension was not worsened or increased by the Veteran's diabetes. VA medical records from an April 2012 compensation and pension examination also showed a diagnosis of hypertension. The examiner stated the hypertension was a complication of diabetes. The rationale given for this conclusion was the severity of the complications. The Board finds that the VA examination reports of record are insufficient to determine whether direct service connection for hypertension is warranted, because none of them addressed service connection on a direct basis for hypertension. The Board finds that the VA examination reports are inadequate to determine secondary service connection for hypertension as well. As noted above, the Veteran contends that his hypertension is secondary to his service connected disability of diabetes. Although the May 2009 VA examiner addressed the secondary service connection issue in the report, he did not discuss aggravation. See Allen v. Brown, 7 Vet. App. 439, 446 (1995) (holding that if aggravation of a veteran's non-service connected disability is proximately due to or the result of a service connected disease or injury, it too shall be service connected for that degree of aggravation; see also 38 C.F.R. § 3.310 (2013) (requiring that service connection not be awarded on an aggravation basis without establishing a pre-aggravation baseline level of disability and comparing it to current level of disability). There appear to be conflicting findings in the May 2009, June 2010, and April 2012 VA examination reports. Therefore, on remand, it is also necessary for the VA examiner to reconcile the conflicting examination findings in the May 2009, June 2010, and April 2012 VA examination reports, as well as the July 2009 VA treatment records. On remand, the Veteran must be afforded a new examination, to specifically include determining whether his hypertension was aggravated by the service-connected disability of diabetes, and reconciling the conflicting VA medical reports. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (finding that when VA undertakes to provide a VA examination, it must ensure that the examination is adequate). Accordingly, the case is REMANDED for the following actions: 1. Schedule the Veteran for an appropriate VA examination by a physician skilled in the diagnosis and treatment of hypertension and diabetes mellitus to determine the nature and etiology of his hypertension. The claims folder must be provided to and reviewed by the examiner. All indicated tests and studies should be performed, and all findings should be set forth in detail. The examiner must offer an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's hypertension is etiologically related to service. The examiner must also provide an opinion as to it is at least as likely as not (a 50 percent probability or greater) the Veteran's hypertension was either (1) caused by or (2) is aggravated by the Veteran's service connected diabetes mellitus type II. If the examiner determines that the hypertension is aggravated by the diabetes, the examiner should report the baseline level of severity of the hypertension prior to the onset of aggravation. If some of the increase in severity of the hypertension is due to the natural progress of the disease, the examiner should indicate the degree of such increase in severity due to the natural progression of the disease. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). All findings must be reported in detail and all indicated testing must be accomplished. The examiner should provide a complete rationale for any opinion rendered and should attempt to reconcile any contradictory evidence of record, including the findings of the May 2009, June 2010, and April 2012 VA examination reports, and the July 2009 VA treatment records. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2011). 2 . Then, after ensuring any other necessary development has been completed, the RO should readjudicate the Veteran's claim. If action remains adverse to the Veteran, provide him and his representative with a supplemental statement of the case and allow an appropriate opportunity to respond. Thereafter, the case should be returned to the Board. The Veteran has the right to submit additional evidence and argument on the matter 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). _________________________________________________ MICHAEL A. PAPPAS 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).