Citation Nr: 1800347 Decision Date: 01/04/18 Archive Date: 01/19/18 DOCKET NO. 17-11 637 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for a generalized anxiety disorder also claimed as major depression disease. 2. Entitlement to service connection for nephrolithiasis also claimed as obstructive uropathy-right kidney s/p. 3. Entitlement to service connection for sensorineural hearing loss claimed as bilateral deafness or bilateral hearing loss disability. 4. Entitlement to service connection for bilateral diabetic peripheral neuropathy of the upper and lower extremities. 5. Entitlement to service connection for Alzheimer's disease stage III-IV (III-IV). 6. Entitlement to service connection for hypertensive cardiovascular disease (hypertension). 7. Entitlement to service connection for colon diverticulosis. 8. Entitlement to service connection for a mental health disability to include posttraumatic stress disorder (PTSD). 9. Entitlement to service connection for diabetes mellitus type II (II). 10. Entitlement to service connection for chronic bronchitis. 11. Entitlement to service connection for individual unemployability due to service-connected disability (TDIU). 12. Entitlement to service connection for dyslipidemia. 13. Entitlement to service connection for glaucoma. 14. Entitlement to service connection for asthma. 15. Entitlement to service connection for tinnitus. ATTORNEY FOR THE BOARD R. M. Harris, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1954 to November 1956. The Veteran served in the Army during the Korean War Era and during Peacetime. This matter is before the Board of Veterans' Appeals (Board) on appeal from a February 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. In that decision the RO denied service connection to all of the Veteran's claimed entitlements to service connection listed in the issues section. In a September 2017 rating decision, the RO granted the Veteran's issue of entitlement to special monthly pension based on the need for aid and attendance effective July 2015 related to his non-service connected disabilities which include hypertension, Alzheimer's, dementia and diabetes mellitus II. As such, this claim is no longer before the Board. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C.A. § 7107(a)(2) (West 2014). For the reasons expressed below, this appeal is being REMANDED to the RO, via the Appeals Management Center (AMC) in Washington, D.C. VA will notify the appellant if further action is required. REMAND (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) The medical evidence of record includes two letters submitted by the Veteran's private physician dated October 2014 and June 2016 reflecting diagnoses of the disabilities for which the Veteran is seeking entitlement to service connection. These diagnoses include: generalized anxiety disorder also claimed as major depression disease, nephrolithiasis also claimed as obstructive uropathy-right kidney s/p, sensorineural hearing loss claimed as bilateral deafness or bilateral hearing loss disability, diabetic peripheral neuropathy of the upper and lower extremities on both the right and left sides, Alzheimer's disease III-IV, hypertensive cardiac disease, colon diverticulosis, PTSD, diabetes mellitus II, chronic bronchitis, dyslipidemia, glaucoma, asthma, and tinnitus. In these letters, the private physician indicates that the Veteran is undergoing prescription drug therapy to treat at least some, if not all, of his diagnosed disabilities including a bronchodilator for a respiratory disability, insulin for diabetes; Lisinopril, and neifedipine which is often used to control high blood pressure; simvastatin and aspirin (ASA) which is commonly used to control cholesterol, zolpidem which is primarily used for insomnia, Paxil and Klonopin which are used to treat depression and anxiety disorders and panic attacks, and gabapentin and which is used to treat seizure. The private physician also states in these letters that the Veteran underwent a right eye surgical procedure related to his glaucoma diagnosis; a right kidney surgical procedure related to his nephrolithiasis diagnosis; and, that the Veteran had been undergoing "comprehensive psychiatric & psychological therapy" related to his major depression disease, Alzheimer's disease and PTSD. However, the medical treatment records which the private physician would have used to make these assessments of diagnosis and treatment on behalf of the Veteran have not been associated with the claim file. The October 2014 and June 2016 letters from the private physician indubitably make reference to medical treatment records upon which the Veteran's diagnoses and treatments were based for the claimed service-connected disabilities, however, such records are not located in the Veteran's claim file. It does not appear, from the available evidence, that any efforts have been made to obtain records of these treatments. Because such records, if obtained, might contain information bearing on the Veteran's appeal, efforts should be made to procure them. See 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c) (2017). Concerning the Veteran's claimed bilateral hearing loss disability and tinnitus; the Veteran underwent a VA examination on August 2015 in which the examiner referenced a June 2008 treatment record diagnosing the Veteran with severe hearing loss in his right ear and mild to profound hearing loss in his left ear. However, this treatment record is not located in the Veteran's file and it does not appear, from the available evidence that any efforts have been made to obtain records of that treatment. Because such records, if obtained, might contain information bearing on the Veteran's appeal, efforts should be made to procure them Regarding the Veteran's diverticulosis of the colon, the Veteran's San Juan VAMC medical treatment records reflect that the Veteran has been diagnosed with diverticulosis of the colon after a colonoscopy examination dated January 2016. The treatment record also states that the results of the colonoscopy were sent to pathology and that the results are pending, but the results are not listed. These records must be obtained. Finally, the Board also notes that the evidence of record indicates that the Veteran may be receipt of disability benefits from the Social Security Administration (SSA). While not clear as to the basis of the award because the records from SSA could contain information pertinent to the issue on appeal, efforts should be made to procure them. See 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c) (2017). Consequently, a remand is necessary in order to obtain any determination pertinent to the Veteran's claim for SSA benefits, as well as any medical records relied upon concerning that claim. See Murincsak v. Derwinski, 2 Vet. App. 363, 369-70 (1992) (where VA has actual notice of the existence of records held by SSA which appear relevant to a pending claim, VA has a duty to assist by requesting those records from SSA). Accordingly, the case is REMANDED for the following action: (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Ask the Veteran to provide a release for relevant records of treatment from Dr. C. E. Mora Quesada, and to identify the names, dates of treatment, and locations (ie. addresses and contact information) for any other private treatments used to diagnose and treat the Veteran; and provide appropriate releases for, any care providers who may possess new or additional evidence pertinent to the issue on appeal. For any identified treatment for which he provides an appropriate release, the identified records must be obtained. Any new or additional (i.e., non-duplicative) evidence received should be associated with the claims file. 2. Obtain any outstanding records pertaining to any relevant treatment the Veteran has received at the San Juan VA Medical Treatment Center not already associated with the file. Specifically, efforts should be made to obtain and associate with the file the June 25, 2008 audiological examination referenced by the August 2015 VA examiner; and, the January 2016 colonoscopy results. All efforts to obtain the outstanding records should be documented in the claim file. If the records are unavailable, the reason for their unavailability should be stated. 3. Ask the Social Security Administration to provide copies of any records in its possession pertaining to its consideration of the Veteran's application for SSA benefits, to include any medical records considered in making a decision on that application. Any new or additional (i.e., non-duplicative) evidence received should be associated with the claim file. 4. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claim should be readjudicated based on the entirety of the evidence. If the issues remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. 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. §§ 5109B, 7112 (2012). _________________________________________________ E. I. VELEZ Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), 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) (2017).