Citation Nr: 1339708 Decision Date: 12/03/13 Archive Date: 12/18/13 DOCKET NO. 12-22 829 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for hypertension. ATTORNEY FOR THE BOARD Avery M. Schonland, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1983 to January 2003. This included deployment to Southwest Asia from December 1990 to April 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2010 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In deciding this appeal, the Board has reviewed the Veteran's electronic (Virtual VA) file, in addition to his physical claims file. Virtual VA is a highly secured electronic repository used to store and review every document involved in the claims process. VA also is in the process of transitioning to an even newer electronic medium, the Veterans Benefits Management System (VBMS). In this case, there are no additional treatment records among the Veteran's paperless records in Virtual VA or VBMS. 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 Veteran submitted several statements attesting to in-service onset for his hypertension, as evidenced by symptoms of headaches and dizziness. The Veteran's service treatment records show elevated blood pressure readings recorded during service. His private treatment records show April 2005 diagnosis for hypertension, with prescription for hydrochlorothiazide. The September 2010 VA examiner offered a negative medical nexus opinion based on diagnosis two years following separation from service. She attributed the in-service elevated blood pressure readings to isolated pain responses and the Veteran's current hypertension to weight gain and an inactive lifestyle. The Veteran's disagrees with the examiner noting that his weight at the time of the April 2005 diagnosis for hypertension was not increased over his in-service weight and that his post-service job as a mover involves strenuous physical activity on a regular basis. The September 2010 VA examiner's opinion appears to be based on an incomplete/inaccurate factual history. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The Board therefore finds that another VA examination and medical opinion is necessary. Additionally, the Veteran receives private treatment for his hypertension, but also receives treatment through the Charlotte Community Based Outpatient Clinic (CBOC) and Salisbury VA Medical Center (VAMC). The most recent private treatment records in the claims file are from March 2010, and the most recent VA treatment records in the claims file are from January 2012. On remand, the AMC should contact the Veteran regarding his authorization to release any outstanding private treatment records, and obtain any outstanding VA treatment records. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should contact the Veteran and ask him to authorize the release of any additional private treatment records. The RO/AMC should then obtain and associate with the claims file any records identified by the Veteran that are not of record. If any requested records are not available, that fact must clearly be documented in the claims file and proper notification under 38 C.F.R. § 3.159(e) should be provided to the Veteran. 2. The RO/AMC should obtain any outstanding treatment records from the Charlotte CBOC and Salisbury VAMC and associate them with the Veteran's claims file, specifically since January 2012. 3. After any outstanding VA or private treatment records have been obtained, the RO/AMC should also schedule the Veteran for a VA hypertension examination. A different examiner than the one performing the September 2010 VA examination should review the claims file in conjunction with the examination, and should opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed hypertension had its onset in-service, or is otherwise related to his military service. The examiner is requested to review all pertinent records associated with the claims file, including the service treatment records, post-service medical records, and the Veteran's credible lay assertions as to in-service onset. The examiner must provide a comprehensive report explaining the basis for all opinions and conclusions reached, citing the relevant facts and objective medical findings from this Veteran as well as any pertinent medical literature supporting the basis for such conclusions. 4. After completing the above, and any other development deemed necessary, readjudicate the Veteran's claim on appeal. If the benefits sought on appeal are not granted in full, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate time for response. The appellant has the right to submit additional evidence and argument on the matter or 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. 2013). _________________________________________________ CHERYL L. MASON 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).