Citation Nr: 1339447 Decision Date: 12/02/13 Archive Date: 12/13/13 DOCKET NO. 12-09 002 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUE Entitlement to service connection for a disability manifested by syncopal episodes and hypoglycemia. REPRESENTATION Appellant represented by: California Department of Veterans Affairs ATTORNEY FOR THE BOARD W. Yates, Counsel INTRODUCTION The Veteran served on active duty from March 1993 to February 2001. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. The appeal is remanded to the RO via the Appeals Management Center in Washington, DC. REMAND The Veteran is seeking entitlement to service connection for a disability manifested by syncopal episodes and hypoglycemia. She attributes this disability to her having been given DEPO-PROVERA contraception injections during service. Remand is required for compliance with VA's duty to assist the Veteran in substantiating her claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). A. Post Service Treatment Records The RO's February 2012 statement of the case refers to the VA treatment records from VA Medical Centers (VAMCs): records dated from May 17, 2005 to July 22, 2010, from the VAMC in Loma Linda, California; records dated from December 11, 2006 to February 29, 2008, from the VAMC in Augusta, Georgia; and records dated from September 12, 2006 to February 2, 2008, from the VAMC in Atlanta, Georgia. A copy of these records are not in the evidence of record. B. Medical Examination Required The Veteran served on active duty in the Air Force from March 1993 to February 2001. Her November 1992 enlistment examination noted essentially normal findings throughout. Service treatment records reflect that the Veteran started receiving DEPO-PROVERA contraception injections in February 1993. Subsequent inservice treatment records reference her complaints of syncopal episodes, which started prior to her military service. Specifically, treatment records in October 1998 and October 1999 noted her history of having syncopal episodes since the age of 12. A May 2000 treatment report noted the Veteran's history of fainting and dizzy spells since the age of 13. The Veteran subsequently underwent an inservice cardiological work up, which was negative. The Veteran contends that she currently has a disability manifested by syncopal episodes and hypoglycemia, secondary to her having been given DEPO-PROVERA contraception injections during service. In her September 2010 notice of disagreement, the Veteran stated, "[i]t wasn't until the first non-military doctor thought to have me check my blood sugar during an episode that we discovered the dizziness was due to extremely low blood sugar." Under these circumstances, the RO must provide the Veteran with a final opportunity to identify or provide additional evidence in support of her claim. In addition, the RO must provide the Veteran with the appropriate examination to determine if she currently has a disability manifested by hypoglycemia and syncopal episodes; and if so, whether such disability is related to her military service. Accordingly, the case is remanded for the following action: 1. The RO must contact the Veteran and afford her the opportunity to identify or submit any additional evidence, to include VA and non-VA medical providers who have treated her for her disability manifested by syncopal episodes and hypoglycemia since her discharge from the service. Based on the Veteran's response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. Regardless of the Veteran's response, the RO must obtain copies of the following VA treatment records, and place a reviewable copy of each in the Veteran's claims file or Virtual VA file: records dated from May 17, 2005 to July 22, 2010, from the VAMC in Loma Linda, California; records dated from December 11, 2006 to February 29, 2008, from the VAMC in Augusta, Georgia; and records dated from September 12, 2006 to February 2, 2008, from the VAMC in Atlanta, Georgia. All attempts to secure this evidence must be documented in the claims file by the RO. When requesting records not in the custody of a Federal department or agency, such as private treatment records, the RO must make an initial request for the records and at least one follow-up request if the records are not received or a response that records do not exist is not received. If the RO is unable to secure any of the identified records, the RO must notify the Veteran and her representative and (a) identify the information the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain that information; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that the Veteran is ultimately responsible for providing information. The Veteran and her representative must then be given an opportunity to respond. 2. Only after completing the above, the Veteran must be afforded the appropriate examination to determine whether she currently has a disability manifested by syncopal episodes or hypoglycemia; and if so, whether this disability is related to the Veteran's military service. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. The claims file and all electronic records must be made available to the examiner, and the examiner must specify in the examination report that these records have been reviewed. Based on the clinical examination, a review of the evidence of record, and with consideration of the Veteran's statements, the examiner must state whether the Veteran currently has a disability manifested by syncopal episodes or hypoglycemia; and if so, whether this disability is related to the Veteran's military service, to include as due to or aggravated by DEPO-PROVERA contraception injections during service. If the examiner finds that a currently diagnosed disability manifested by syncopal episodes or hypoglycemia preexisted service, the examiner must specifically state what evidence of record this finding is based. The examiner must then determine whether this disability increased in severity beyond the normal progression during active military service. If the examiner finds that a currently diagnosed disability manifested by syncopal episodes or hypoglycemia increased in severity beyond the normal progress during active military service, the examiner must state upon what factual evidence in the record this finding was made. If the examiner finds that a currently diagnosed disability manifested by syncopal episodes or hypoglycemia did not increase in severity beyond the normal progress during active military service, the examiner must state upon what factual evidence in the record this finding was made. A complete rationale for all opinions must be provided. If the examiner cannot provide the requested opinions without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner 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 examiner. 3. The RO must notify the Veteran that it is her responsibility to report for the scheduled examination, and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2013). In the event that the Veteran does not report for the scheduled examination, documentation must be obtained and associated with the Veteran's claims file that shows that notice scheduling the examination was sent to her last known address. Documentation must be also be obtained and associated with the Veteran's claims file demonstrating any notice that was sent was returned as undeliverable. 4. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim remaining on appeal must be readjudicated. If the claim remains denied, a supplemental statement of the case must be provided to the Veteran and her representative. After the Veteran and her 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 she receives further notice; however, she may present additional evidence or argument while the case is in remand status at the RO. 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 (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) (2013).