Citation Nr: 1341748 Decision Date: 12/18/13 Archive Date: 12/31/13 DOCKET NO. 10-27 779 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island THE ISSUES 1. Entitlement to an initial rating in excess of 20 percent for the service-connected diabetes mellitus. 2. Entitlement to service connection for left kidney failure. 3. Entitlement to service connection for pancreatitis. 4. Entitlement to service connection for peripheral neuropathy, right upper extremity. 5. Entitlement to service connection for peripheral neuropathy left upper extremity. 6. Entitlement to service connection for peripheral neuropathy, right lower extremity. 7. Entitlement to service connection for peripheral neuropathy, left lower extremity. 8. Entitlement to service connection for stasis dermatitis. 9. Entitlement to a total disability rating based on individual unemployability (TDIU) by reason of service-connected disability. REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Turner, Counsel INTRODUCTION The Veteran served on active duty from October 1966 to July 1968. This matter comes before the Board of Veterans' Appeals (Board) on an appeal from a November 2009 rating decision issued by the RO. The Veteran testified at a hearing held at the RO before the undersigned Veterans Law Judge in May 2012. The appeal is being remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required on his part. REMAND The Veteran asserts that he should receive a higher initial rating for his service-connected diabetes mellitus. He also claims that the service-connected diabetes mellitus caused his claimed pancreatitis, left kidney failure, stasis dermatitis and peripheral neuropathy of all of his extremities. At his hearing, the Veteran testified that he had a private primary care physician who treated him for diabetes mellitus and his various other ailments. He also testified that he saw another private physician for his kidney problems. Additionally, he was treated at a private hospital for acute pancreatitis in June 2007 and in the spring of 2010. None of the records from the two private physicians mentioned by the Veteran at his hearing are in the claims file. Further, although there is a June 2007 private hospital discharge summary pertaining to an episode of acute alcoholic pancreatitis in the Veteran's Social Security Administration (SSA) disability file, very few other treatment records from this hospital are in the claims file. Moreover, there are no records from the 2010 episode of pancreatitis when the Veteran claimed that his gall bladder was removed. These records may provide relevant information about the nature and etiology of the Veteran's claimed disabilities, especially in light of the fact that a September 2009 VA examination found no evidence of current pancreatitis, severe renal disease, or peripheral neuropathy. The Board also finds that another VA examinations should be scheduled since the Veteran claims that some of his conditions had worsened since the September 2009 VA examination. At that examination, the Veteran denied recurrences of pancreatitis. The VA treatment records show that, in May 2010, he told a doctor that he was recently treated at a private hospital for pancreatitis and still had residual abdominal pain. At his hearing in May 2012, the Veteran testified that, due to pancreatitis, his gall bladder was removed a few years earlier at a private hospital. He added that he still experienced episodes of abdominal pain, although these were not severe enough to cause him to seek hospital treatment. Thus, there is some evidence that the Veteran still has some residual disability due to the claimed pancreatitis, to include the removal of his gall bladder. He submitted an internet article suggesting a link between diabetes and acute pancreatitis. Therefore, another VA examination should be scheduled in order to determine whether he does have any residual pancreas disability that is due to an event or incident of service or to his service-connected diabetes mellitus. The Veteran also claimed that he had suffered left kidney failure. A December 2006 CT scan showed renal calculi and atrophy of the left kidney with hydronephrosis. Later private treatment records referenced the Veteran having only one functioning kidney. Although no "severe" kidney disease was found at the recent VA examination, the Veteran may have an underlying condition related to the previously noted left kidney manifestations. Additionally, at his hearing, the Veteran testified that he had recurrent symptoms of blood in his urine that could be related to a kidney condition such as the hydronephrosis diagnosed in 2006. The cause of the blood in the urine is not apparent from the available treatment records. Since some kidney problem may exist, the Veteran should be afforded another examination in order to fully evaluate his kidney condition. No peripheral neuropathy was found in connection with the VA examination in September 2009. At that time, the only reported symptoms related to his lower extremities. The examiner thought that they could be related to a nonservice-connected spine disorder. At his May 2012 hearing, the Veteran testified that he also developed numbness in his hands that caused him to lose grip of his canes. Since he claims that his symptoms have progressed, another VA examination should be scheduled to determine whether any peripheral neuropathy is related to the service-connected diabetes mellitus. With respect to the claimed venous stasis ulcers, the VA examiner opined these were related to the Veteran's morbid obesity. However, at his hearing, the Veteran testified that his ulcers took very prolonged periods to heal and that he was seen at a VA wound clinic. Finally, while the Veteran has not specifically asserted that his diabetes mellitus has worsened since the prior examination, he should be afforded another VA examination of determine the current severity of the service-connected diabetes mellitus. As the issue of a TDIU rating is inextricably intertwined with the service connection and increased rating claim, further action as to this matter must be deferred. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are 'inextricably intertwined' when they are so closely tied together that a final Board decision cannot be rendered unless both issues have been considered). Accordingly, the case is REMANDED for the following action: 1. The RO should take appropriate steps to contact the Veteran and request that he identify, and provide appropriate releases for all medical treatment he has received for the service-connected diabetes mellitus and the claimed pancreatitis, kidney disease, peripheral neuropathy, and venous stasis ulcers, including the doctors and hospitals that he mentioned at his May 2012 hearing. If the Veteran provides appropriate releases, copies of all identified private treatment records should be obtained for review. If records are identified but cannot be obtained, then the attempts that were made to obtain the records should be documented in the claims file and the Veteran should be provided with appropriate notice that the records were not received. Copies of all VA treatment records since 2009 should also be obtained to the extent that they are not already in the claims file. 2. After the aforementioned records are received (or are determined to be unavailable), the RO should have the Veteran scheduled for a VA examination to determine the current severity of the service-connected diabetes mellitus and the nature and likely etiology of the claimed secondary conditions. The examiner(s) should review the entire claims file in connection with the examination(s). All necessary tests and studies should be carried out. The examiner should address the following: (1) Identify all symptoms of the service-connected diabetes mellitus, including whether regulation of activities is required in order to control hypoglycemic events. All functional effects should be fully documented in the examination report. (2) Determine whether the Veteran has a current pancreas disability that at least as likely as not (at least 50 percent likely) was caused or aggravated (made permanently worse) by a disease or injury in service or by the service-connected diabetes mellitus. (3) Determine whether the Veteran has a current kidney disability to include any related to left kidney failure or hydronephrosis that at least as likely as not was caused or aggravated by a disease or injury in service or by the service-connected diabetes mellitus. (4) Determine whether the Veteran has a current disability manifested by peripheral neuropathy that at least as likely as not was caused or aggravated by a disease or injury in service or by the service-connected diabetes mellitus. (5) Determine whether the Veteran has a current disability manifested by venous stasis ulcers that at least as likely as not was caused or aggravated by the service-connected diabetes mellitus. The examiner(s) should provide a complete rationale for each opinion expressed in the report of examination, including discussion of the relevant findings and medical principles underlying the opinion. If the examiner(s) is unable to provide any of the requested opinions without resort to undue speculation, he or she should explain why this is the case. 3. After completing all indicated development, the RO should readjudicate the claims remaining on appeal in light of all the evidence of record. If any benefits sought on appeal remains denied, the Veteran and his representative should be furnished with a fully responsive Supplemental Statement of the Case and afforded a reasonable opportunity for response. Thereafter, if applicable, the case should be returned to the Board for the purpose of appellate disposition. The Veteran 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. 2012). _________________________________________________ STEPHEN WILKINS 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).