Citation Nr: 1643516 Decision Date: 11/16/16 Archive Date: 12/01/16 DOCKET NO. 12-27 191A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUE Entitlement to service connection for hypertension, claimed as secondary to service-connected diabetes mellitus, type II. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD Debbie A. Breitbeil, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from April 1969 to January 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a May 2010 rating decision by the Indianapolis, Indiana Department of Veterans Affairs (VA) Regional Office (RO). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND The Veteran alleges that his diagnosed hypertension is secondary to his service-connected diabetes mellitus, type II. He underwent a VA examination in April 2010, in order to determine the etiology of his claimed disability. The examining physician opined that his "essential" hypertension was not related to diabetes because diabetes was not an independent risk factor for hypertension and there was no renal involvement. The examiner further opined, without any supporting rationale, that the Veteran did not have any conditions that were aggravated by diabetes. Subsequent to the VA examination, the Veteran submitted two statements, dated in June 2010 and February 2011, from his private treating physician (Dr. Underwood), who indicated that he started the Veteran on Toprol XL [a medication to treat cardiovascular problems such as angina and high blood pressure] back in September 2003 as part of his diabetic treatment. He opined, without further explanation, that the Veteran's hypertension was "most likely secondary to his underlying diabetes." Thereafter, VA outpatient records in the file, as noted in the statement of the case in September 2012, show that in July 2012 the Veteran's hypertension was "optimally controlled" and his blood pressure reading was 134/73. The July 2012 record also indicates that the Veteran's diabetes mellitus was "suboptimally controlled." In April 2016, the Veteran submitted a statement in support of his claim, asserting that since his July 2012 outpatient visit to VA, VA has increased "by 100%" his daily prescribed dosage of Toprol XL, in addition to his prescribed Lisinopril. He contended that this increased medication dosage was evidence showing that his hypertension was becoming difficult to control. In other words, he seemed to imply that his hypertension was becoming worse and that his diabetes mellitus was responsible for the progression. (He also appeared to feel that his worsening hypertension had an adverse effect on his diabetes.) The Board finds that the record, including the VA opinion, is inadequate and additional development is needed in order to decide the claim. First, there are no VA outpatient records to reflect that the Veteran's hypertensive medication has been increased since his July 2012 visit, particularly as the only VA records obtained for association with the claims file after that outpatient visit are dated in August 2014 and October 2015 and neither provide a listing of the Veteran's prescribed medications. Thus, in light of the Veteran's assertions that his hypertension has worsened, possibly as a result of aggravation by diabetes, the RO should seek to obtain updated VA outpatient records. By extension, the Veteran should be asked to submit any updated private treatment records. Second, as earlier noted, the VA examiner did not provide any explanation for the opinion that the service-connected diabetes mellitus did not aggravate hypertension. A medical examination report must contain not only clear conclusions with supporting data but also a reasoned medical explanation explaining the conclusion being reached. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). It is observed that the Veteran's representative in an October 2016 written argument cited to medical articles and general medical information concerning the co-existence of hypertension and diabetes mellitus in individuals. Thus, after obtaining all updated treatment records, the RO should return the examination report to the examiner for an addendum opinion to address the deficiencies of the April 2010 examination report. Accordingly, the case is REMANDED for the following action: 1. The AOJ should request the Veteran to submit records of treatment for hypertension and diabetes mellitus from his private physician (Dr. Underwood) since April 2001 (i.e., the date of the last treatment report from the doctor in the claims file), or submit a medical release to authorize VA to obtain them on his behalf. 2. The AOJ should obtain for association with the claims file updated VA outpatient records pertaining to the Veteran's treatment for hypertension and diabetes mellitus since July 2012. 3. Thereafter, the AOJ should return the record to the April 2010 VA examiner for an addendum opinion, or if unavailable, arrange for a VA examination of the Veteran in order to determine the etiology of his hypertension. The claims file must be reviewed by the examiner in conjunction with the examination. The examiner should provide an opinion as to whether the Veteran's currently diagnosed hypertension at least as likely as not (a 50 percent or greater probability) was caused or aggravated by his service-connected diabetes mellitus, type II. If the opinion is to the effect that the diabetes mellitus did not cause but aggravated the hypertension, the examiner should also specify, so far as medically discernible, the degree of disability (pathology/impairment) resulting from such aggravation. The examiner is advised that aggravation is defined for legal purposes as a chronic worsening of the underlying condition (versus a temporary flare-up of symptoms) beyond its natural progression. The examiner must include rationale, with citation to supporting factual data and medical literature where appropriate, for all opinions. 4. Following completion of the foregoing development, the AOJ should readjudicate the Veteran's claim of service connection for hypertension to include as secondary to service-connected diabetes mellitus, type II. If the benefit sought remains denied, the AOJ should issue an appropriate supplemental statement of the case, afford the Veteran and his representative opportunity to respond, and return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter 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 for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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 the Veteran's appeal. 38 C.F.R. § 20.1100(b) (2015).