Citation Nr: 1340989 Decision Date: 12/12/13 Archive Date: 12/20/13 DOCKET NO. 12-04 615 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for hypertensive vascular disease, to include as secondary to service-connected diabetes mellitus. 2. Entitlement to service connection for a vision disorder, diagnosed as suspected glaucoma and anterior ischemic optic neuropathy, to include as secondary to service-connected diabetes mellitus. ATTORNEY FOR THE BOARD Mary-Caitlin Ray, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1968 until January 1973. These matters come to the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. 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's review of the record reveals that further RO action on the claims on appeal is warranted. The Veteran served in Vietnam and Korea for an unknown period of time and in March 2009 was granted presumptive service connection for diabetes mellitus due to herbicide exposure. See 38 C.F.R. § 3.309(e) (2013). In this appeal, the Veteran claims that he has developed hypertension and a vision disorder due to his diabetes mellitus. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2013). Service connection may also be granted for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (2013). Service connection is permitted not only for a disability caused by a service-connected disability, but also for the degree of disability resulting from aggravation to a nonservice-connected disability by a service-connected disability. See id; see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). VA will provide a medical examination or obtain a medical opinion if the evidence indicates the existence of a current disability or persistent or recurrent symptoms of a disability that may be associated with an event, injury, or disease in service, but the record does not contain sufficient medical evidence to decide the claim. 38 U.S.C.A. § 5103A(d)(2)(West 2002); 38 C.F.R. § 3.159(c)(4)(i) (2013); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Furthermore, once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide one that is adequate for purposes of the determination being made. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). To be considered adequate, the medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions." Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Veteran has submitted medical records from the VA Medical Center (VAMC) in Jackson, Mississippi, which indicate that he is currently taking medication for "heart/blood pressure" See May 2008 VA Treatment Record. Ophthalmology records from the same facility indicate that he has been diagnosed with anterior ischemic optic neuropathy with suspected glaucoma. The Veteran underwent a VA examination in 2009 to determine the etiology of his hypertension. The examiner opined that the record did not indicate that the Veteran had a diagnosis of hypertension and further stated that it would be speculative to make such a diagnosis based on the evidence before him. As for rationale for any potential diagnosis of hypertension, the examiner stated only, "any hypertension in this patient's case at this point in time would be essential and not caused by or due to his diabetes." August 2009 VA Examination Report. The examiner acknowledged the Veteran's use of the blood pressure medication Lisinopril but speculated that he could be taking it for kidney protection, as opposed to hypertension. This appears contradictory to the clinical records but is without adequate explanation. VA ophthalmological records show that the Veteran is followed for diagnoses of suspected glaucoma and anterior ischemic optic neuropathy. It is repeatedly noted that there is no retinopathy due to diabetes. A VA opinion was obtained in December 2009 to determine the etiology of the Veteran's eye disorder. The examiner opined that neither glaucoma nor ischemic optic neuropathy is related to diabetes mellitus. As for rationale, the examiner stated only, "anterior ischemic optic neuropathy is thought to have as one etiology a circulatory vascular insufficiency to the optic nerve and it would be pure speculation to suggest that diabetes is the cause of this." December 2009 VA Opinion. Neither of these opinions provides the Board with sufficient medical information to make a decision on these claims. Crucially, both opinions fail to address whether the Veteran's service-connected diabetes mellitus aggravated his current disorders. See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (concluding that statements regarding the relationship between two conditions do not encompass a discussion of aggravation). Consequently, a remand to secure further medical advisory opinions is necessary. Accordingly, the case is REMANDED for the following actions: 1. Obtain and associate with the claims file any additional relevant medical evidence that may have come into existence since the August 2009 VA hypertension examination report. 2. Send the Veteran a letter requesting that the Veteran provide sufficient information, and if necessary, authorization to enable the RO to obtain any additional evidence pertinent to the claim. The RO should specifically request that the Veteran submit any records related to a diagnosis of hypertension. 3. If the Veteran responds, assist him in obtaining any additional evidence identified. All records/responses received should be associated with the claims file. If any records sought are not obtained, the RO should notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 4. Attempt to obtain an opinion or clarification from the Veteran's primary care physician(s), from VA, private provider, or both, to discern whether the Veteran has hypertension. In so doing, attempt to confirm the reason for prescribing Lisinopril; specifically, to determine whether it is for control of hypertension or for kidney protection, or both. Request an opinion as to the following question: whether it is at least as likely as not (i.e., a probability of 50 percent or more) that any diagnosed hypertension was caused or aggravated (worsened beyond the normal progression) by the Veteran's service-connected diabetes mellitus. In this case aggravation means that the hypertension is proximately due to or the result of a service-connected disability. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation. 5. In the event that the development requested above is unobtainable, schedule the Veteran for a VA examination, if possible with an internal medicine physician, to determine the diagnosis and etiology of his claimed hypertension. All necessary tests and studies shall be conducted, and the claims file should be made available for the examiner for review in conjunction with the examination. The examiner shall opine: a) whether the Veteran has hypertension, specifically addressing the Veteran's use of Lisinopril; b) and if so, whether it is at least as likely as not (i.e., a probability of 50 percent or more) that any diagnosed hypertension was caused or aggravated (worsened beyond the normal progression) by the Veteran's service-connected diabetes mellitus. In this case aggravation means that the hypertension is proximately due to or the result of a service-connected disability. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation. 6. Concerning the vision disorder claim, return the claims file to the physician who rendered the December 2009 opinion, or if unavailable to another appropriate examiner, for an addendum addressing the following question: Is it at least as likely as not(i.e., a probability of 50 percent or more) that the Veteran's diagnosed vision disorder(s) was aggravated (worsened beyond the normal progression of the disease) by the Veteran's service-connected diabetes mellitus. In this case aggravation means that the vision disorder is proximately due to or the result of a service-connected disability. If the Agency of Original Jurisdiction (AOJ) determines that hypertension is a service-connected residual of diabetes, then aggravation of the vision disorder by hypertension shall be considered in the opinion as well. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation. 7. In rendering the requested opinions, the examiner(s) should specifically consider and discuss the Veteran's contentions, the lay history of symptomatology, and all the relevant medical evidence of record. A rationale for all medical opinions shall be provided. If the examiner(s) cannot provide an opinion without resorting to mere speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner(s) shall explain whether inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 8. Upon completion of the above-requested development, the RO should readjudicate the claims on appeal, taking into account all available evidence and conducting any additional development deemed necessary. If the service connection claims remain denied, the Veteran should be provided with a Supplemental Statement of the Case as to the issue remaining on appeal, and afforded a reasonable period of time within which to respond thereto. 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). These claims 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). _________________________________________________ JONATHAN B. KRAMER 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).