Citation Nr: 1720141 Decision Date: 06/07/17 Archive Date: 06/21/17 DOCKET NO. 10 48-808 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for neurological impairment of the bilateral upper extremities, claimed as peripheral neuropathy, as secondary to service-connected type 2 diabetes mellitus. 2. Entitlement to service connection for scars/tightness, as secondary to a neurological impairment of the bilateral upper extremities. 3. Entitlement to service connection for hypertension, as secondary to service-connected type 2 diabetes mellitus. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD N. Riley, Associate Counsel INTRODUCTION The Veteran had active duty service from February 1967 to February 1969. This appeal to the Board of Veterans' Appeals (Board) arose from a November 2009 rating decision in which the RO denied the Veteran's claims for service connection for carpal tunnel syndrome claimed as bilateral neuropathy of the upper extremities, hypertension, and scars. In November 2009, the Veteran filed a notice of disagreement (NOD). A statement of the case (SOC), pertaining to the issues of service connection for hypertension and scars, was issued in September 2010. The Veteran filed a VA Form 21-4138, Statement in Support of Claim, in November 2010 which the RO accepted as a substantive appeal in lieu of a VA Form 9, Appeal to the Board of Veterans' Appeals. The RO issued a supplemental SOC (SSOC) addressing these claims in September 2014. . In January 2016, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge at the RO. A transcript of the hearing has been associated with the claims file. In July 2016, the RO issued the Veteran a separate SOC addressing his claim for service connection for a neurological condition of the bilateral upper extremities. Although the Veteran previously had a paper claims file, this appeal is now being processed utilizing the paperless, electronic Veterans Benefits Management System (VBMS) and Virtual VA claims processing systems. Regarding characterization of that portion of the appeal involving a service connection for neurological impairment of the upper extremities, the Board notes that the RO characterized this claim as a request to reopen a previously denied claim. In an April 2015 rating decision, the RO found that new and material evidence to reopen the claim had been received and adjudicated the claim for service connection on the merits. The Board points out, however, that the Veteran initially filed a claim characterized as one for service connection for peripheral neuropathy. in September 2005. The RO originally denied the claim in a December 2005 rating decision; the basis for the denial was that there was no diagnosis of peripheral neuropathy. Specifically, the RO explained that a July 2005 examiner opined the Veteran's complaints of peripheral neuropathy were as likely as not related to his diagnosed carpal tunnel syndrome. The Veteran submitted a written statement in August 2006 stating, inter alia, that his peripheral neuropathy in his upper extremities had worsened. In December 2006, the RO sent a letter requesting the Veteran clarify if he is submitted additional medical evidence. Following that letter, the AOJ readjudicated and again denied the claim for service connection for peripheral neuropathy by way of a February 2007 rating decision. The Veteran filed an NOD in October 2007 and the RO issued an SOC in April 2009 continuing to deny the claim. In May 2009, the Veteran submitted a statement requesting an examination, for, among other things, peripheral neuropathy of the upper extremities. In June 2009, the RO sent notice to the Veteran hat his peripheral neuropathy claim was still pending and his statement could not be processed because his claim was already on appeal. In July 2009, the Veteran submitted medical treatment for carpal tunnel syndrome. The RO issued the previously mentioned November 2009 rating decision, characterizing the claim as service connection for carpal tunnel syndrome and denying the claim. The Veteran's representative submitted a statement in November 2009 filing an NOD for "peripheral neuropathy, bilateral upper extremities." The RO did not ask for clarification and instead treated the correspondence as an NOD for the previously discussed issues of hypertension and scars only. Under these circumstances, the Board finds that, as the evidence reflects the continuous prosecution of a claim for service connection for neurological impairment affecting the bilateral upper extremities (however characterized), and no final denial of such a claim, the Veteran's March 2005 claim for service connection for peripheral neuropathy of the upper extremities remains pending, and de novo adjudication is appropriate. See 38 U.S.C.A. §§ 5108, 7105 (West 2014); 8 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2016); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011). Furthermore, given the evidence of record, and what the AOJ has adjudicated, the Board has generally characterized the claim as one involving neurological impairment of the upper extremities ,claimed as peripheral neuropathy (as reflected on the title page). The Board's decisions addressing the service connection claims for neurological impairment affecting the bilateral upper extremities, and for scars/tightness secondary to such impairment, are set forth below. The claim for service connection for hypertension is addressed in the remand following the order; this matter is being remanded to the agency of original jurisdiction (AOJ). VA will notify the Veteran when further action, on his part, is required. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each claim herein decided have been accomplished. 2. There is no evidence or argument that neurological impairment of the bilateral upper extremities, diagnosed as carpal tunnel syndrome, had its onset during, or is otherwise medically related to service. 3. There is no competent evidence or opinion indicating that the Veteran's diabetes caused his carpal tunnel syndrome, and the only competent, probative opinion to address whether the Veteran's diabetes has aggravated his carpal tunnel syndrome weighs against the claim. 4. As service connection for neurological impairment of the upper extremities has not been established, there is no legal basis for an award of service connection for scars on a secondary basis. CONCLUSIONS OF LAW 1. The criteria for service connection for neurological impairment of the bilateral upper extremities, claimed as peripheral neuropathy, as secondary to service-connected type 2 diabetes mellitus, are not met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310(a) (2016). 2. The claim for service connection for scars/tightness, as secondary to neurological impairment of the bilateral upper extremities, is without legal merit. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2016). After a complete or substantially complete application for benefits is received, notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim, as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the AOJ. Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, in a June 2005 (neurological condition) and September 2009 (scars) pre-rating letters, the AOJ provided notice to the Veteran explaining what information and evidence was needed to substantiate the claims for service connection for peripheral neuropathy and scars, what information and evidence must be submitted by the appellant, and what information and evidence would be obtained by VA. Both letters provided to the Veteran general information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. The December 2005 and November 2009 rating decisions reflect the initial adjudication of the claims after issuance of these letters. The record also reflects that, consistent with applicable duty-to-assist provisions, VA has made reasonable efforts to develop the claims herein decided, to include obtaining or assisting in obtaining all relevant records and other evidence pertinent to these claims. Pertinent medical and other objective evidence associated with the claims file consists of service, VA, and private treatment records, Social Security Administration records, and the reports of multiple VA neurological examinations. Also of record and considered in connection with the appeal is the transcript of the Veteran's January 2017 Board hearing, along with various written statements provided by the Veteran. The Board finds that no additional AOJ action to further develop the record in connection with either claim, prior to appellate consideration, is required. As for the Board hearing, the Board notes that, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge (VLJ) who chairs a hearing to fulfill two duties: (1) to fully explain the issues and (2) to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, the Board finds that there has been substantial compliance with the duties set forth in 38 C.F.R. 3.103(c)(2), and that the hearing was legally sufficient. Here, during the Board hearing, the VLJ identified the issues then on appeal. Also, information was solicited regarding the Veteran's experiences during active service, his current symptoms and treatment, and whether there were outstanding, pertinent medical records. Although the undersigned did not explicitly suggest the submission of any specific, additional evidence, on these facts, such omission was harmless. Simply stated,, nothing prior to, at the time of, or since the hearing, gave rise to the possibility that there is any existing, outstanding evidence relevant yo these claims to obtain or submit.497. In summary, the duties imposed by the VCAA have been considered and satisfied. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. As such, there is no prejudice to the Board proceeding to decision on each claim herein decided, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534 (Fed. Cir. 1998). II. Analysis Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. § 3.303(a) (2016). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Id; see also Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); Under 38 C.F.R. § 3.310(a), service connection also may be granted for disability that is proximately due to or the result of a service-connected disease or injury. That regulation permits service connection not only for disability caused by service-connected disability, but for the degree of disability resulting from aggravation to a nonservice-connected disability by a service-connected disability. See 38 C.F.R. § 3.310 (2015). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Effective October 10, 2006, VA amended 38 C.F.R. § 3.310 with regard to the requirements for establishing secondary service connection on an aggravation basis. See 71 Fed. Reg. 52,744 - 47 (Sept. 7, 2006). In rendering a decision on appeal, the Board must analyze the competency, credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102 (2016); Gilbert, supra. At the outset, the Board notes that, although the AOJ considered the claim for service connection for neurological impairment of the bilateral upper extremities on both direct and secondary theories of entitlement, there is actually no evidence or allegation that the diagnosed disability-carpal tunnel syndrome-had its onset during, or is otherwise medically-related to, service. The service treatment records are negative for any complaints, finding or diagnosis related to carpal tunnel syndrome. No carpal tunnel syndrome was shown, nor is alleged to have been diagnosed, during service. Moreover, as indicated below, there is no documented evidence of carpal tunnel syndrome for 29 years after service-a factor that would tend to weigh against a claim for direct service connection if, in fact, a relationship to service was being asserted. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). Here, however, the Veteran has only asserted that his carpal tunnel syndrome is secondary to his diabetes. Given the complete absence of evidence or allegation that carpal tunnel syndrome is service related, any further discussion or development on the question of direct service connection is unnecessary, and the Board will limit its discussion to secondary service connection. In this case, the Veteran has been awarded service connected for diabetes. The medical evidence of record does not indicate an exact date of the initial diagnosis of diabetes; however a June 2000 VA outpatient treatment record indicates the Veteran's initial VA treatment for diabetes. The medical evidence further reflects an initial diagnosis of carpal tunnel syndrome by a private provider in March 1996. At that time, the Veteran reported he had injured his right trigger finger while working as a car buffer in July 1985 when it was hyperextended while operating the buffing machine. He further stated that the gradual numbness in the right fingers spread to his left hand after continuing to operating the same buffing machine for many years following that. The private provided diagnosed carpal tunnel syndrome and stated it was related to his work place accident in 1985 and "27 years of hard manual labor." The provider did not note any diagnosis of diabetes. The Veteran underwent VA examinations for his claimed neurological impairment in July 2005 and September 2008. Both examiners ruled out a diagnosis peripheral neuropathy of the upper extremities; however, neither offered an opinion concerning any relationship between the Veteran's diabetes and the diagnosed carpal tunnel syndrome. The Veteran was afforded another VA examination in June 2016. Following a physical examination and a review of the Veteran's claims file, the examiner noted that she could not form an opinion as to whether the Veteran's carpal tunnel syndrome was related to his diabetes, without resort to mere speculation. The examiner opined diabetes increases the likelihood of mononeuropathies such as carpal tunnel syndrome, however "I cannot resolve without resort to mere speculation if the veteran's carpal tunnel syndrome was caused or aggravated by his type 2 diabetes." As explanation, the examiner noted carpal tunnel syndrome might also develop independently of diabetes. The Board points out that the VA examiner's conclusion that he could not reach an opinion without resort to mere speculation, cannot be construed herein as an actual medical opinion weighing either for or against the claim. See Fagan v. Shinseki, 573 F.3d 1282, 1289 (Fed. Cir. 2009). Neither the Veteran nor his representative has presented, identified, or alluded to the existence of a medical opinion supporting a finding of secondary service connection on the basis of causation, and, as noted, the June 2016 examiner stated that an opinion could not be provided without resort to mere speculation. In cases involving a VA examiner's finding that an opinion cannot be rendered without resorting to speculation, the Court has noted that VA is not required to proceed through multiple iterations of repetitive medical examinations until it has obtained a conclusive opinion or formally declares that further examinations would be futile. Jones v. Shinseki, 23 Vet. App. 382, 387 (2010). It must be clear, however, from some combination of the examiner's opinion and the Board's analysis of the record, that the examiner has not invoked the phrase "without resort to mere speculation" as a substitute for full consideration of all pertinent and available medical facts. Id. The United States Court of Appeals for Veterans Claims (Court) has prescribed that such a standard requires that the examiner's assessment be made after all due diligence has been exercised in seeking relevant medical information that may have bearing on the requested opinion. Id at 389. Although a bald statement by the examiner that it would be speculative to render an opinion as to etiology or diagnosis is fraught with ambiguity, the Board may rely on an examiner's conclusion that an opinion would be speculative if such an opinion is supported by an explanation of the basis for such an opinion or is otherwise apparent in the Board's review of the evidence. Id. at 390. VA must also ensure that it is clear, from either the examiner's statements or the Board decision, that the examiner has considered "all procurable and assembled data" by obtaining all tests and records that might reasonably illuminate the medical analysis. Id. (quoting Daves v. Nicholson, 21 Vet. App. 246 (2007)). Thus, the examiner's use of the phrase "without resort to mere speculation" should reflect the limitations of knowledge in the medical community at large and not those of a particular examiner. Finally, the examiner should clearly identify precisely which facts cannot be determined. In this case, in June 2016, the VA examiner offered an explanation of how he reached the conclusion that he could not render an opinion without resort to mere speculation. It is clear that his conclusion was not based on a lack of expertise or the need for additional testing. As discussed above, the examiner explained that carpal tunnel syndrome and diabetes may develop independently of one another. Given the explanation provided by the VA examiner, and the fact that the examiner clearly considered all relevant evidence and facts, the Board accepts the June 2016 VA examiner's statement that an etiology opinion could not be provided without resort to speculation, and finds that no further action on the matter of whether the Veteran's diabetes caused his carpal tunnel syndrome is warranted Here, there simply is no competent, probative evidence or opinion supporting the Veteran's contention that his currently diagnosed carpal tunnel syndrome is medically related to his service-connected diabetes. In fact, in the only opinion of record to address the question of etiology of carpal tunnel syndrome, the March 1996 private provider determined that the Veteran's carpal tunnel syndrome was related to a post-service work place injury. The Board has reviewed VA outpatient treatment records and observes that such records do not contain any evidence that the Veteran's diabetes aggravated his carpal tunnel syndrome. Again, there is no contrary, competent evidence or opinion even suggesting a secondary relationship-on the basis of causation or aggravation. Thus, the Board finds that the only competent, probative opinion on the question of secondary service connection weighs against the claim. Furthermore, to whatever extent the Veteran attempts to establish the etiology of his carpal tunnel syndrome on the basis of his own lay assertions, alone, such attempt must fail. Matters of diagnosis and etiology of the complex disability here issue is based on internal processes not observable to the human eye; hence, questions of diagnosis and etiology of such a disability are only within the province of individuals with special knowledge, training, and experience. See Kahana v. Shinseki, 24 Vet. App. 428, 433, 438 (2011). See also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). As the Veteran is simply not shown to have such special knowledge, training, and experience, his assertions in this regard are not competent, and hence, not probative. As indicated, the e opinion of the VA examiner is the only competent, probative opinion on this point, and that opinion weighs against the claim. In reaching the conclusion to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claims, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. With regard to claimed scars/tightness, the Board further points out that, the Veteran contends that service connection for such is warranted secondary to neurological impairment of the bilateral upper extremities. However, there is no legal basis of granting service connection for such disability on this basis, as the Veteran has not been awarded service connection for any such neurological impairment. Where, as here, service connection for a primary disability has not been awarded, the Veteran cannot establish entitlement to service connection, pursuant to 38 C.F.R. § 3.310(a), for a secondary condition. Thus, any assertions as to entitlement to secondary service connection for scars/tightness secondary of diagnosed carpal tunnel syndrome of the bilateral upper extremities are without legal merit. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Accordingly, the claims for service connection for a neurological impairment of the bilateral upper extremities as secondary to diabetes mellitus, and for scars/tightness, as secondary to neurological impairment of the bilateral upper extremities, must be denied. (CONTINUED ON NEXT PAGE) ORDER Service connection for neurological impairment of the bilateral upper extremities, claimed as peripheral neuropathy, as secondary to service-connected type 2 diabetes mellitus, is denied. Service connection for scars/tightness, as secondary to neurological impairment of the bilateral upper extremities, is denied. REMAND The Board's review of the claims file reveals that further action on the remaining claim on appeal is warranted. The Veteran asserts that his hypertension is the result of his service-connected type 2 diabetes mellitus. During his January 2017 Board hearing, the Veteran stated that it was his service-connected diabetes that was causing his current hypertensive condition. Notably, a November 2010 letter from the Veteran's VA provider seems to suggest the Veteran's hypertension may be due to his service-connected diabetes. In the present case, the Board notes the record contains the reports of January 2011 and August 2014 examinations, which include opinions addressing the Veteran's hypertension claim. The Board finds, however, that the opinions contained in these reports do not sufficiently resolve the claim. On VA examination in January 2011, the examiner diagnosed hypertension and opined that this condition was not caused by his service-connected diabetes, as diabetes can cause hypertension if there is nephropathy; however, that was not shown to be present in the Veteran. On August 2014 VA examination, the examiner again diagnosed hypertension. In finding the Veteran's hypertension not related to his diabetes, the examiner provided only the rationale that while diabetes and hypertension frequently coexist, diabetes does not cause hypertension. Thus, neither examiner explicitly addressed whether the Veteran's hypertension is or had been aggravated (worsened beyond natural progression) by his diabetes. See Allen, 7 Vet. App. at 448 (an opinion that something "is not related to" or "is not due to" does not answer the question of aggravation). Because the medical opinions of record fail to adequately address the issue of secondary service connection, a new VA examination, by an appropriate physician, to obtain complete opinions is needed to fairly resolve the remaining claim on appeal. See 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159 (2016); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). See also. Barr v. Nicholson, 21 Vet. App. 303 (2007). (holding that when VA provides an examination or obtains an opinion in connection with a service connection claim, even when not legally obligated to do so, it must provide or obtain one that is adequate for the purposes sought). The Veteran is hereby notified that failure to report to the scheduled examination, without good cause, may well result in denial of the claims. See 38 C.F.R. § 3.655 (2016). Examples of good cause include, but are not limited to, the illness or hospitalization of the Veteran and death or an immediate family member. Prior to arranging for the Veteran to undergo VA examination, to ensure that all due process requirements are met., and that the record is complete, the AOJ should give the Veteran another opportunity to provide additional information and/or evidence pertinent to the remaining claim on appeal, explaining that he has a full one-year period for response. See 38 U.S.C.A. § 5103(b)(1) (West 2014); but see also 38 U.S.C.A. § 5103(b)(3) (clarifying that VA may make a decision on a claim before the expiration of the one-year notice period). The AOJ should specifically request that the Veteran furnish, or furnish appropriate authorization to obtain, all outstanding, pertinent private (non-VA) records. Thereafter, the AOJ should attempt to obtain any additional evidence for which the Veteran provides sufficient information, and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159 (2016). The actions identified herein are consistent with the duties imposed by the VCAA. See 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2016). However, identification of specific actions requested on remand does not relieve the AOJ of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the AOJ should also undertake any other development and/or notification action deemed warranted by the VCAA prior to adjudicating the remaining claim on appeal. Accordingly, this matter is hereby REMANDED for the following action: 1. Send to the Veteran and his representative a letter requesting that the Veteran provide sufficient information, and if necessary, authorization to obtain any additional evidence pertinent to the remaining claim on appeal that is not currently of record. Specifically request that the Veteran provide, or provide appropriate authorization to obtain, all outstanding, pertinent, private (non-VA) records. Clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claim within the one-year period). 2. If the Veteran responds, assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 3. After all records and/or responses received from each contacted entity have been associated with the claims file, or, a reasonable time period for the Veteran's response has expired, arrange for the Veteran to undergo VA examination, by an appropriate physician, in connection with his service connection claim for hypertension. The contents of the entire, electronic claims file (in VBMS and Virtual VA), to include a complete copy of this REMAND, must be made available to the designated physician, and the examination report should include discussion of the Veteran's documented medical history and assertions. All necessary tests and studies should be accomplished (with all findings made available to the examiner prior to the completion of his or her report), and all clinical findings should be reported in detail for the disability at issue. With respect to diagnosed hypertension, the examiner should render an opinion, consistent with sound medical judgment, as to whether it is at least as likely as not (i.e. a 50 percent or greater probability that the disability (a) was caused OR (b) is or has been aggravated (worsened beyond natural progression) by service-connected type 2 diabetes mellitus. If aggravation is found, the examiner should attempt to quantify the extent of additional disability resulting from the aggravation, to include by identifying, to the extent possible, the baseline level of disability prior to aggravation. In addressing the above, the examiner must consider and discuss all relevant medical and other objective evidence, as well as all lay assertions. All examination findings/testing results, along with complete, clearly stated rationale for the conclusions reached, must be provided. 4. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. Stegall v. West, 11 Vet. App. 268 (1998). 5. After completing the requested actions, and any additional notification and/or development deemed warranted, adjudicate the remaining claim on appeal in light of all pertinent evidence (to include all that added the VBMS and/or Virtual VA file(s) since the last adjudication) and legal authority. 6. If the benefit sought on appeal remains denied, furnish to the Veteran and his representative a supplemental SOC that includes clear reasons and bases for all determinations, and afford them an appropriate time period for response. The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication; it is not the Board's intent to imply whether any benefit requested should be granted or denied. The Veteran need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999)). This REMAND must be afforded expeditious treatment. The law requires that all claims 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 2014). _________________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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 the appeal. 38 C.F.R. § 20.1100(b) (2016).