Citation Nr: 1801746 Decision Date: 01/10/18 Archive Date: 01/23/18 DOCKET NO. 15-18 882 ) 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 hypertension, to include as secondary to service-connected diabetes mellitus type II. 2. Entitlement to service connection for traumatic arthropathy involving hands. 3. Entitlement to service connection for muscle spasms. 4. Entitlement to service connection for osteopenia. 5. Entitlement to service connection for major depressive disorder, to include as secondary to service-connected conditions. 6. Entitlement to service connection for dizziness, vertigo. 7. Whether new and material evidence has been presented to reopen a claim of service connection for keratoderma, plantar heels. 8. Entitlement to service connection for keratoderma, plantar heels. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD LM Stallings, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1963 to November 1965. These matters are before the Board of Veterans' Appeals (Board) on appeal from an October 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran was afforded a hearing before a Decision Review Officer at the RO in April 2016. A transcript of the hearing has been associated with the claims file. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The issues of service connection for osteopenia, dizziness and vertigo, hypertension, to include as secondary to service connected diabetes mellitus type II, and major depressive disorder, to include as secondary to service-connected disabilities are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Muscle spasms were not manifested in service, were not manifested within one year following the Veteran's separation from service; and the preponderance of the evidence is against findings that his current muscle spasms are etiologically related to his service. 2. Traumatic arthropathy of the hands was not manifested in service, was not manifested within one year following the Veteran's separation from service; and the preponderance of the evidence is against findings that his current traumatic arthropathy of the hands is etiologically related to his service. 3. A January 1969 Board decision denied an appeal to restore service connection for keratoderma, plantar heels. The Veteran was properly notified of the decision. 4. The evidence added to the record since the January 1969 Board decision is neither cumulative nor redundant and raises a reasonable possibility of substantiating the claim seeking service connection for keratoderma, plantar heels. 5. The Veteran's keratoderma, plantar heels clearly and unmistakably preexisted his entrance into service. However, it is not shown by clear and unmistakable evidence that keratoderma, plantar heels was not aggravated by service. 6. The evidence is at least in equipoise as to whether the Veteran's keratoderma, plantar heels is etiologically related to his active duty service. CONCLUSIONS OF LAW 1. The criteria for service connection for muscle spasms have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 2. The criteria for service connection for traumatic arthropathy of hands have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The January 1969 Board decision is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. 4. Evidence received since the January 1969 Board decision is new and material and the claim is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 5. The criteria for service connection for keratoderma, plantar heels have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Neither the Veteran nor his representative has raised any issues with the duty to notify. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). VA's duty to assist also includes providing a medical examination and/or obtaining a medical opinion when necessary to make a decision on the claim, as defined by law. See 38 U.S.C. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board acknowledges that the Veteran has not been afforded a VA examination for his claims for service connection for muscle spasms and service connection for traumatic arthropathy of hands. However, an examination is not necessary in order to render a decision on those claims. In disability compensation claims, the Secretary must provide an examination when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies; (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability; and (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon, 20 Vet. App. at 83-86. Additionally, a VA examination is necessary when the record contains competent evidence that the Veteran has persistent or recurrent symptoms of the claimed disability and the record indicates that those symptoms may be associated with active military service. Duenas v. Principi, 18 Vet. App. 512 (2004). As discussed further below, the Board finds that the second and third McLendon elements have not been met for the Veteran's claims for service connection for muscle spasms and service connection for traumatic arthropathy of the hands. There is no evidence establishing an in-service event or injury and there is no evidence indicating the Veteran disabilities are associated with service. As such, remand to afford the Veteran an examination is not necessary. See Bardwell v. Shinseki, 24 Vet. App. 36, 39-40 (2010) (finding that VA is not required to provide a medical examination when there is no credible evidence of an event, injury, or disease in service). Neither the Veteran nor his representative has raised any other issues with the duty to assist. See Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Legal Criteria and Factual Analysis Service Connection Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To substantiate a claim of service connection, there must be evidence of: a present claimed disability; incurrence or aggravation of a disease or injury in service; and a causal relationship between the claimed disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). When no preexisting injury or disease is noted upon entry into service, the Veteran is presumed to have been sound upon entry. See 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). The burden then falls on the government to rebut the presumption of soundness by finding clear and unmistakable evidence that the Veteran's injury or disease was both pre-existing and not aggravated by service. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). If the presumption of soundness is not rebutted, the Veteran is entitled to service-connected benefits. See id. Service connection is also warranted for a disability that is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. The elements of a successful secondary service connection claim are evidence: (1) of a disability for which service connection is sought; (2) of a disability that is already service connected; and (3) that the service-connected disability caused or aggravated the disability for which service connection is sought. The determination as to whether these requirements are met is based on analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The competence, credibility, and probative (relative) weight of evidence, including lay evidence must be assessed. See generally 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis when a layperson (1) is competent to identify the unique and readily identifiable features of a medical condition; or, (2) is reporting a contemporaneous medical diagnosis; or, (3) describes symptoms at the time which supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Muscle Spasms The Veteran claims he is entitled to service connection for muscle spasms. VA treatment records from 2005 indicate that the Veteran was diagnosed with muscle spasm. Therefore, the record reflects the Veteran has a current diagnosis of muscle spasms, and the first element of the claim for service connection has been met. What remains to be established is that the Veteran's muscle spasm is related to his period of active duty service or a service-connected disability. With respect to the second element of service connection, an in-service event or injury, service records do not indicate treatment, diagnosis, or injuries during service for any muscle spasms. The November 1965 separation examination reflects no complaints of muscle spasms. The Veteran's first indication of muscle spasms was in June 2005. An April 2016 VA Form 4138, Statement in Support of Claim, from the Veteran indicated that his muscle spasm was in his lower back. However, there is no indication in his service treatment records or his separation examination that he had an injury to his lower back, or an incident involving his lower back, while in service. As such, the second element of service connection has not been met. With respect to the third element of service connection, a medical nexus between the disability and in-service event, the record does not contain an opinion or reference to the Veteran's service as a cause or source for the Veteran's claimed muscle spasms. As such, the claim fails on this basis as well. Consideration has been given to the Veteran's assertions that his muscle spasms are related to service. However, while lay persons are competent to provide opinions on some medical issues, the specific issues in this case fall outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Muscle spasms are not conditions that are readily amenable to lay comment regarding etiology. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). The Board acknowledges that the Veteran is competent to report observable symptoms, but there is no indication that he is competent to etiologically link any symptoms or diagnoses. He is not shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that he received any special training or acquired any medical expertise in evaluating these disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Accordingly, the lay evidence does not constitute competent medical evidence and lacks probative value. As such, a preponderance of the evidence is against the claim and entitlement to service connection for muscle spasms is not warranted and must be denied. Traumatic Arthropathy of the Hands The Veteran claims he is entitled to service connection for traumatic arthropathy of the hands. VA treatment records from 2011 indicate that the Veteran suffers from traumatic arthropathy of the hands. Therefore, the record reflects the Veteran has a current diagnosis of traumatic arthropathy of the hands, and the first element of the claim for service connection has been met. What remains to be established is that the Veteran's traumatic arthropathy of the hands is related to his period of active duty service or a service-connected disability. With respect to the second element of service connection, an in-service event or injury, service records do not indicate treatment, diagnosis, injuries, or symptoms during service related to traumatic arthropathy of hands. The November 1965 separation examination reflects no complaints related to traumatic arthropathy of the hands. The Veteran claims the first indication of traumatic arthropathy of hands was in March 2006. As such, the second element of service connection has not been met. With respect to the third element of service connection, a medical nexus between the disability and in-service event, the record does not contain an opinion or reference to the Veteran's service as a cause or source for the Veteran's claimed traumatic arthropathy of the hands. As such, the claim fails on this basis as well. As such, entitlement to service connection for traumatic arthropathy of the hands is not warranted and must be denied. Consideration has been given to the Veteran's assertions that his traumatic arthropathy of the hands is related to service. However, while lay persons are competent to provide opinions on some medical issues, the specific issues in this case fall outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377; Kahana, 24 Vet. App. at 435. Traumatic arthropathy of the hands is not a condition that is readily amenable to lay comment regarding etiology. See Davidson, 581 F.3d 1313; Woehlaert v. Nicholson, 21 Vet. App. at 462. Accordingly, the lay evidence lacks probative value. Based on the above, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for traumatic arthropathy of the hands. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, the Veteran's claim must be denied. Keratoderma, plantar heels New and Material Evidence The Veteran was granted service connection for keratoderma, plantar heels in an April 1966 rating decision. Service connection was severed in a January 1968 rating decision. The Veteran was properly notified of the decision, filed a timely notice of disagreement, and a statement of the case (SOC) affirming the decision was issued in July 1968. The Veteran filed a VA Form 9, Substantive Appeal, in August 1968 and the Board denied the appeal seeking to restore service connection in an August 1969 decision. The Board provided the Veteran with proper notification of the decision. At the time the decision was issued, there was no right to appeal the Board's decision. Therefore, the August 1969 Board decision is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. Generally, when a claim is disallowed, it may not be reopened and allowed, and a claim based on the same factual basis may not be considered. 38 U.S.C. § 7105. However, a claim on which there is a final decision may be reopened if new and material evidence is submitted. 38 U.S.C. § 5108. The question of whether new and material evidence has been received to reopen a claim must be addressed in the first instance by the Board as the issue goes to the Board's jurisdiction to reach the underlying claim and adjudicate it on a de novo basis. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). If the Board finds that no such evidence has been offered, this is where the Board's analysis must end; hence, what the RO may have determined in this regard is irrelevant. Jackson, 265 F.3d at 1369. "New" evidence means existing evidence not previously submitted to agency decision makers. "Material" evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156(a). New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. Id. When determining whether a claim should be reopened, the credibility of the newly submitted evidence is to be presumed. Fortuck v. Principi, 17 Vet. App. 173, 179-80 (2003); Justus v. Principi, 3 Vet. App. 510 (1992). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly received evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA Secretary's duty to assist or through consideration of an alternative theory of entitlement. Shade, 24 Vet. App. at 118. The August 1969 Board decision declined to re-establish service connection for keratoderma, plantar heels based on a finding that the disability preexisted service, was not identified or treated in service, and was treated again more than three months after service. Evidence received since the August 1969 Board decision includes a VA examination report dated in April 2016, in which the examiner stated the Veteran's pre-existing keratoderma, plantar heels, was clearly and unmistakably aggravated beyond its natural progression by his service. This evidence is new in that it was not previously of record. This evidence is material in that it provides evidence of an in-service event; namely, aggravation beyond its natural progression of a pre-existing condition. This evidence is not cumulative or redundant and raises a reasonable possibility of substantiating the claim of service connection. 38 C.F.R. § 3.156(a); Shade v. Shinseki, 24 Vet. App. 110 (2010), Justus, 3 Vet. App. at 513. Therefore, it is both new and material and the claim is thereby reopened. Service Connection The record includes multiple treatment records and a VA examination report that show the Veteran has had keratoderma, plantar heels during the appeal period. For example, on April 2016 VA examination, keratoderma, plantar heels, originally diagnosed in April 1966, was noted. The examiner noted that the Veteran currently uses a topical cream for treatment on a constant/near-constant basis. Therefore, the first element of service connection has been met. Regarding the second element of service connection, as will be explained below, evidence of record raises a question as to whether the Veteran had keratoderma of the plantar heels that preexisted his entrance into service. The presumption of soundness applies to "every veteran," but only attaches where such veteran is examined, accepted, and enrolled for the period of service in question, and where such examination does not reveal defects, infirmities, or disorders. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Before the presumption of soundness can be applied, there must be evidence that a disability or injury that was not noted on entrance into service manifested or was incurred in service. See Gilbert v. Shinseki, 26 Vet. App. 48, 52 (2012). Where there is evidence showing that a disorder manifested or was incurred in service, and this disorder is not noted on the Veteran's entrance examination report, the presumption of soundness operates to shield the Veteran from any finding that the unnoted disease or injury preexisted service. Id. In this case, on VA examination in March 1966 the examiner noted that the Veteran had experienced scaling and fissures of both heels since he was in service. An April 1966 VA Dermatology Examination noted that the skin over the region of the heels was thick, yellowish-white, verrucose showing deep fissures at times. The examiner noted that the condition had been present "for a good many years, sometimes better and sometimes worse." Since the evidence is at least in equipoise as to whether keratoderma of the plantar heels was manifested during the Veteran's active service, the Board turns to the issue of whether the Veteran was presumed sound at entry into service. Gilbert, 26 Vet. App. at 52. The December 1963 entrance examination report does not reflect that a skin-related foot condition was noted; therefore, the Veteran is presumed sound at entrance and the presumption of soundness attaches. 38 C.F.R. § 3.304(b)(1)-(2). To overcome the presumption of soundness, the burden falls on the government to rebut the presumption of soundness by finding clear and unmistakable evidence that the Veteran's injury or disease was both preexisting and not aggravated by service. See Wagner, 370 F.3d at 1096. Regarding preexistence, the April 1966 VA Dermatology examiner indicated that the skin condition of the feet had been present "for a good many years." Additionally, on April 2016 VA examination, the VA examiner reviewed the Veteran's record and based on that review, opined that the Veteran's keratoderma of the plantar heels had preexisted his service. However, the Board finds that there is not clear and unmistakable evidence of record that the preexisting condition was not aggravated by service. Specifically, on April 2016 VA examination, the VA examiner reviewed the Veteran's record, including the Veteran's January 1966 claim for compensation, which requested an examination for a foot condition, and the March and April 1966 VA examination reports and concluded that the keratoderma had been aggravated beyond the natural progression of the condition by the Veteran's service. Based on this opinion, the Board finds that there is not clear and unmistakable evidence that the preexisting keratoderma of the plantar heels was not aggravated by the Veteran's service. Accordingly, the presumption of soundness has not been rebutted and the in-service event element of the claim of service connection has been met. The critical question remaining is whether there is competent evidence of a nexus between the keratoderma, plantar heels and the Veteran's service. The April 2016 VA examiner stated that the Veteran's current skin condition of the feet is the same condition he had while in, and for which he sought treatment immediately following service. The examiner also noted that the Veteran has consistently reported the same type of lesions on his feet since leaving service. In light of the positive April 2016 VA opinion, the Board finds that the evidence is at least in equipoise on the question of whether there is a nexus between the Veteran's service and his current disability. Therefore, affording the Veteran the benefit of the doubt, service connection for keratoderma, plantar heels, is warranted. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for muscle spasm is denied. Service connection for traumatic arthropathy of the hands is denied. As new and material evidence has been received, the claim of service connection for keratoderma, plantar heels, is re-opened and service connection is granted. REMAND The Veteran asserts that he is entitled to service connection for osteopenia, dizziness and vertigo, hypertension, to include as secondary to service-connected diabetes mellitus, and major depressive disorder (MDD), to include as secondary to service-connected disabilities. Unfortunately, these issues must be remanded to ensure that the Veteran is afforded every possible benefit. Osteopenia The Veteran claims he is entitled to service connection for osteopenia. VA treatment records reflect a diagnosis of osteopenia. The Veteran was afforded a VA Bones examination in October 2014. The examination report reflects that the Veteran complained of upper and lower bone pain, which comes and goes. Diagnostic testing revealed that the Veteran was negative for osteopenia in his upper extremities and his spine. While the examiner concluded that diagnostic testing was negative for osteopenia in the upper extremities and spine, diagnostic testing was not performed on the Veteran's lower extremities nor did the examiner provide an opinion or supporting rationale for why the Veteran's claimed osteopenia was or was not related to his service. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (holding that once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, VA must ensure that the examination provided is adequate). An adequate medical opinion must contain not only clear conclusions, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The examiner's opinion contained diagnostic test results but without associated opinions or analysis. Therefore, on remand, the Veteran must be afforded another VA examination to ensure that the Veteran's lower extremities are provided appropriate diagnostic testing, as well as an opinion and supporting rationale with discussion of the facts and medical principles involved. Dizziness and Vertigo The Veteran claims he is entitled to service connection for dizziness and vertigo. September 2015 VA treatment records reflect a diagnosis of chronic vertigo. The Veteran was afforded a VA examination in October 2014, wherein the Veteran was diagnosed with peripheral vestibular disorder. Although the examination was conducted in conjunction with the Veteran's claim of service connection, the October 2014 VA examiner did not provide an opinion on the matter of service connection of the vertigo and peripheral vestibular disorder. As the VA examination is inadequate, the claim must also be remanded for a new VA examination. See Barr, 21 Vet. App. 303. Hypertension, to include as secondary to service-connected diabetes mellitus II The Veteran also contends that he is entitled to service connection for hypertension, to include as secondary to his service-connected diabetes mellitus type II. An April 2016 VA examination report notes that the Veteran's hypertension is less likely than not secondary to his diabetes mellitus type II on the premise that his diagnosis of hypertension pre-dates his diagnosis of diabetes mellitus type II by more than seven years. The examiner noted that examination in April 2016 was the first time his microalbumin/creatinine ratio was noted to be suggestive of nephropathy, but the examiner noted that he was found to have adequate blood pressure readings. The examiner continued that "there is no evidence of permanent aggravation beyond the natur[al] course of the disease." The Board finds this opinion to be inadequate. Regarding aggravation, the opinion appears to rely on an incorrect standard of aggravation. Specifically, the aggravation standard for a secondary service connection claim does not require that the nonservice-connected disability be permanently aggravated. Rather, 38 C.F.R. § 3.310(b) states that "any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected." Further, regarding whether diabetes caused hypertension, pursuant to the recent case, Frost v. Shulkin, 2017 U.S. Vet. App. Claims LEXIS 1747 (Nov. 30, 2017), the United States Court of Appeals for Veterans Claims (Court) held that the mere fact a claimed disability pre-dates the service-connected disability, the Board may not rely on that fact in denying service connection on a secondary basis. As such, an addendum opinion must be obtained with medical support beyond a statement that the claimed condition pre-dated the service-connected condition, and therefore causation is not possible. Therefore, on remand, the file should be returned to the April 2016 VA examiner to provide an addendum opinion addressing secondary service connection causation in light of the ruling in Frost, as well as an adequate opinion regarding aggravation. MDD, to include as secondary to service-connected disabilities Regarding the Veteran's claim for service connection for MDD, to include as secondary to service-connected disabilities, the Board finds it is inextricably intertwined with the claims of entitlement to service connection for hypertension or service connection for osteopenia. January 2014 VA treatment records reflect a current diagnosis of MDD, and indicate that Axis III of the diagnosis was based on hypertension, hyperlipidemia, colon polyps, and osteopenia. Axis III diagnoses report general medical conditions that are potentially relevant to the understanding or management of an individual's mental disorder. DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 39 (4th ed. 1994). Hence, this record indicates a potential relationship between the Veteran's MDD and the claimed disabilities of hypertension and osteopenia. As the matters of service connection for hypertension and service connection for osteopenia must be remanded for adequate examinations, the current appeal for MDD, to include as secondary to service-connected disabilities, must also be remanded pending adjudication of the inextricably intertwined claims. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). Additionally, the record reflects the Veteran receives continuing VA treatment. The most recent VA treatment records are from April 2016. Therefore, any updated VA records should be obtained and associated with the claims file on remand. Accordingly, the case is REMANDED for the following actions: This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested. 1. Obtain VA treatment records from April 2016 to the present. 2. After completing the development requested in item 1, return the claims file to the April 2016 VA examiner who performed the examination for hypertension for further comment. If the examiner is not available, provide the claims file to an appropriate VA examiner for an addendum opinion. The examiner should review the claims file, specifically the April 2016 VA examination and opinion. The examiner should then answer the following: Is it at least as likely as not (50 percent probability or more) that the Veteran's diagnosed hypertension is causally related to or aggravated (any worsening beyond the natural course of the disability) by the Veteran's diabetes mellitus, type II? If the examiner determines an additional examination is required to sufficiently address the above question, then a new examination should be afforded. A complete rationale should be provided for all opinions provided. If any requested opinion cannot be provided without resorting to speculation, court cases require the examiner to explain why the opinion cannot be offered, and state whether the inability is due to the absence of any evidence or is due to the limits of scientific or medical knowledge. 3. After completing the development requested in item 1, schedule the Veteran for appropriate VA examination(s) for osteopenia and dizziness and vertigo. Any necessary tests and studies must be completed. The electronic claims file must be made available to the examiner(s) for review in conjunction with the examination. A report of the examination(s) should be prepared and associated with the Veteran's VA claims file. The electronic claims file must be made available to the examiner(s). Based on review of the pertinent evidence of record, (and any tests, studies or examination deemed necessary) the examiner(s) should provide the following opinions: (a) Does the Veteran have a current diagnosis of osteopenia or dizziness and vertigo? (b) If the answer to (a) is yes, is it at least as likely as not (50 percent or better probability) that the Veteran's osteopenia and/or dizziness and vertigo is related to his active duty service or any incident therein, to include striking his head in the shower? (c) If the answer to (b) is that it is less likely than not, then is it at least as likely as not (50 percent or better probability) that the Veteran's osteopenia and/or dizziness and vertigo is caused or aggravated by (where aggravation is any increase in severity beyond the natural progress of the disability) any of his service-connected disabilities? A complete rationale should be provided for all opinions provided. If any requested opinion cannot be provided without resorting to speculation, court cases require the examiner to explain why the opinion cannot be offered, and state whether the inability is due to the absence of any evidence or is due to the limits of scientific or medical knowledge. 4. If any of the above development results in a benefit being granted, do the additional development as deemed necessary (an opinion or additional examination) to evaluate whether the Veteran's MDD is caused or aggravated by (where aggravation is any increase in severity beyond the natural progress of disability) any of his service-connected disabilities. 5. After completing the above development, and any other development deemed necessary, readjudicate the Veteran's claims based on the entirety of the evidence. If any benefit sought on appeal is not granted in full, he and his representative should be provided with a supplemental SOC. An appropriate period of time should be allowed for response. The Veteran has the right to submit additional evidence and argument on the 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 for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112. ______________________________________________ M. Sorisio Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs