Citation Nr: 1339675 Decision Date: 12/03/13 Archive Date: 12/18/13 DOCKET NO. 12-29 719 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to service connection for hypertension, to include as secondary to service-connected coronary artery disease and diabetes mellitus. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD D. Whitehead, Counsel INTRODUCTION The Veteran had active service from June 1962 to June 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. The appeal is remanded to the RO via the Appeals Management Center in Washington, DC. REMAND The Veteran claims that his currently diagnosed hypertension is caused or aggravated by his service-connected coronary artery disease and diabetes disabilities. In February 2010, the Veteran underwent a VA examination to determine whether hypertension was related to his military service or to a service-connected disorder. Based on the clinical findings and a review of the Veteran's VA medical records, the examiner opined that the Veteran's hypertension was not caused or aggravated by his diet controlled diabetes mellitus or coronary artery disease. However, the examiner indicated that the claims file was not reviewed in conjunction with performing the examination. Thus, the examiner did not review or consider the complete evidence of record, to include relevant private medical evidence. Following the February 2010 VA examination, the Veteran submitted an August 2010 statement from L. P. Z., M.D., who noted the Veteran's diabetes, coronary artery disease, and hypertension diagnoses. Dr. Z. stated that there was a direct correlation between Agent Orange exposure and diabetes. He further stated that diabetes impacted the cardiovascular system, leading to hypertension and coronary artery disease. The private physician, however, did not directly comment as to the relationship, if any, between the Veteran's hypertension and his diabetes and coronary artery disease. Thus, his statement, alone, is not sufficient with which to grant the Veteran's claim. Given the foregoing, the Board finds the medical evidence of record currently of record is inadequate with which to decide the Veteran's claim. Specifically, the February 2010 VA opinion does not give full consideration to all of the evidence of record, and Dr. Z.'s August 2010 statement does not directly address any possible relationship between the Veteran's hypertension and his service-connected disabilities. Thus, an additional medical opinion as to whether the Veteran's hypertension is related to his military service or to a service-connected disorder must be obtained, giving full consideration to all pertinent evidence. See 38 U.S.C.A. § 5103A(d) (West 2002); 38 C.F.R. § 3.159(c)(4) (2013); Colvin v. Derwinski, 1 Vet. App. 171 (1991) (finding that when the medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion or ordering a medical examination.). 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, the RO must attempt to obtain and associate with the evidence of record all outstanding VA records or private treatment records identified by the Veteran that are relevant to the claim on appeal, to include records from Dr. J. A. M. and Dr. L. P. Z. 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. 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 obtaining all outstanding records, the evidence of record must be provided to a physician with sufficient expertise to determine whether the Veteran's hypertension is related to his military service or to a service-connected disorder. The claims file, all electronic records must be made available to the examiner, and the examiner must specify in the examination report that theses records have been reviewed. Based on the clinical examinations, a review of the evidence of record, and with consideration of the Veteran's statements, the examiner must opine as to whether the Veteran's hypertension is related to his military service. The examiner must also opine as to whether the Veteran's hypertension was caused or aggravated by a service-connected disability, to include coronary artery disease and diabetes mellitus. Any opinion provided must include a complete rationale for the opinion. If the examiner cannot provide the requested opinion 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. The report prepared must be typed. 3. After the requested medical opinion has been provided, the RO must review the medical report to ensure that it is in complete compliance with the directives of this remand. The report must be returned to the examiner if it is deficient in any manner and the RO must implement corrective procedures at once. 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 above, the claim on appeal must be readjudicated. If the 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, he 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 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).