Citation Nr: 1342828 Decision Date: 12/26/13 Archive Date: 01/07/14 DOCKET NO. 09-40 797 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Caylor, Associate Counsel INTRODUCTION The Veteran had active military service from March 1970 to October 1971. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The Board has reviewed the physical claims file and the Virtual VA electronic claims file. 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 remands the claim on appeal for additional development because the record does not contain an adequate medical opinion. The Veteran appears to have two contentions: (1) his hypertension was caused by his diabetes mellitus because it is a long-term complication of diabetes and he did not have it until he was diagnosed with diabetes mellitus; and, (2) based on an October 1971 in-service blood pressure reading, his hypertension was noted in service and there is continuity of symptomatology. See October 2009 substantive appeal; December 2013 appellate brief. The Veteran underwent VA examinations regarding the nature and etiology of any diabetes mellitus and hypertension in 2008, 2010, and 2012. "[O]nce the Secretary undertakes the effort to provide an examination when developing a service-connection claim, . . . he must provide an adequate one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). An adequate medical opinion must consider all relevant evidence of record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). It must consider the veteran's prior pertinent medical history and must also include clear conclusions, supporting data, and a reasoned medical explanation. Barr, 21 Vet. App. at 311; Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Finally, it must consider all raised theories of entitlement. Stefl, 21 Vet. App. at 120. Service connection may be granted for disability that is proximately due to or the result of service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); 38 C.F.R. § 3.310(a). An adequate opinion regarding secondary service connection claims must specify whether the Veteran's prior service-connected disability "caused or aggravated" his or her current claimed disability. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310. The October 2008 VA examiner diagnosed the Veteran with diabetes mellitus and hypertension. After reviewing the claims file, the examiner opined that the Veteran's hypertension was not caused by or related to his diabetes mellitus. The rationale was that it was unclear when he was diagnosed with either diabetes or hypertension and he had no history of coronary artery or peripheral arterial disease. This opinion is inadequate because it does not consider all theories of entitlement. While the examiner did provide an opinion and a rationale, the examiner did not provide an opinion regarding whether the Veteran's diabetes mellitus aggravated his hypertension beyond its natural progression. Therefore, the examiner failed to consider entitlement based on secondary service connection. The August 2010 VA examiner diagnosed the Veteran with diabetes mellitus, type two, and essential hypertension, of unknown etiology. The examiner opined that it was less likely than not caused by or related to service or a service-connected condition because the Veteran was diagnosed with hypertension after service at approximately the same time that he was diagnosed with diabetes and he had known risk factors, including a positive family history and natural aging. This opinion is inadequate because the examiner did not consider prior pertinent medical history or consider all theories of entitlement. The examiner did not review the claims file, which contains the Veteran's service treatment records (STRs), and private treatment records showing diagnoses and treatment for both diabetes mellitus and hypertension. The failure to review the Veteran's STRs is especially pertinent because the Veteran is now asserting that he incurred hypertension in service. While the examiner did provide a medical opinion and a rationale, the examiner did not consider entitlement based on secondary service connection due to aggravation. The June 2012 VA examiner diagnosed the Veteran with diabetes mellitus, type two; essential hypertension, of unknown etiology; and hypogonadism, of unknown etiology. The examiner found there were no objective complications of diabetes, but there were other pertinent or related conditions-hypertension and hypogonadism. An opinion immediately follows the mention of hypogonadism and simply states, "Not caused by or related to service or service-connected condition," and, "No evidence of worsening beyond natural progression." This opinion is inadequate because the examiner did not review the claims file and failed to provide clear conclusions or a medical explanation or rationale. As mentioned above, the failure to review the claims file means that prior pertinent medical evidence, including the Veteran's STRs and pertinent private treatment records, was not considered. While the opinion refers to "worsening beyond natural progression," it does not specify what was worsened or aggravated or whether it applies only to hypogonadism or to both hypogonadism and hypertension. Further, the examiner did not provide a medical explanation or rationale. Consequently, the RO should provide the Veteran with a new opinion on the basis of direct and secondary service connection that provides clear reasoning and incorporates all pertinent medical evidence in the record, including the Veteran's STRs and private treatment records. Accordingly, the case is REMANDED for the following action: 1. First, undertake appropriate development to obtain any outstanding, pertinent medical records, including from VA and private physician, Dr. M. 2. Then, provide the Veteran with a new VA opinion, by an examiner with sufficient expertise, to determine the nature and etiology of any current hypertension. Provide the examiner with the claims file, including any pertinent evidence in Virtual VA that is not already in the claims file. The examiner should review the claims file and perform all indicated studies. The examiner should provide an opinion, based on examination results and the record, as to the following: A. whether it is at least as likely as not (a 50 percent or greater probability) that any current hypertension is etiologically related to the Veteran's active service or was manifest within one year of service discharge; B. whether it is at least as likely as not (a 50 percent or greater probability) that any current hypertension is proximately due to the Veteran's service-connected diabetes mellitus; and C. whether it is at least as likely as not (a 50 percent or greater probability) that any current hypertension is aggravated (chronically worsened) by the Veteran's service-connected diabetes mellitus. The opinion must consider all pertinent medical history, including the Veteran's STRs and private treatment records, and contain both a detailed description of the disabilities and a complete medical rationale. 3. The RO or AMC should undertake any additional development it deems warranted. 4. Then, the RO or AMC should readjudicate the claim on appeal. If the benefits sought on appeal are not granted to the Veteran's satisfaction, the Veteran and his representative should receive a Supplemental Statement of the Case and an opportunity to respond. If necessary, the case should then be returned to the Board for further appellate action. 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. 2012). _________________________________________________ S. L. Kennedy 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).