Citation Nr: 1804771 Decision Date: 01/25/18 Archive Date: 02/05/18 DOCKET NO. 14-07 847 ) 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 (diabetes) and herbicide agent exposure. 2. Entitlement to service connection for a vascular disability, to include arteriosclerosis obliterans. REPRESENTATION The Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Grace J. Suh, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1971 to February 1973, which included service in the Republic of Vietnam during the Vietnam Era. For his service, he received the National Defense Service Medal, Vietnam Service Medal, and Republic of Vietnam Campaign Medal with 60 device. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Commonwealth of Puerto Rico. In a July 2016 rating decision, the RO granted the Veteran's service connection claims for peripheral neuropathy of the right upper extremity, left upper extremity, right lower extremity, and left lower extremity. As such, the maximum benefit available for these claims was awarded, and they are no longer before the Board. See AB v. Brown, 6 Vet. App. 35 (1993). In an August 2017 administrative decision, the RO reconsidered and confirmed its May 2017 denial of the Veteran's claims for an earlier effective date prior for the award of service connection for peripheral neuropathy of the right upper extremity, left upper extremity, right lower extremity, and left lower extremity. See August 2017 Letter to the Veteran; May 2017 Rating Decision. In response, his representative submitted a November 2017 letter expressing their disagreement with the August 2017 administrative decision. While the RO has yet to acknowledge receipt of the November 2017 letter, given the recency of the filing, the Board finds no action is required at this juncture. See Manlincon v. West, 12 Vet. App. 238 (1999). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). The VA will notify the Veteran if further action is required. REMAND I. VA Treatment Records In a November 2010 Statement in Support of Claim, the Veteran informed the RO that he has been receiving treatment at the San Juan VA medical center (VAMC). A review of the claims file shows his VA treatment records from San Juan only go as far back as January 20, 2012. Thus, a remand is necessary to obtain all VA treatment records from the San Juan VAMC prior to January 20, 2012. II. Service Connection for Hypertension The Veteran contends that his hypertension is secondary to his service-connected diabetes. See October 2010 Statement in Support of Claim. In the alternative, the Veteran's representative submitted his hypertension is secondary to his presumed herbicide agent exposure in service. December 2017 Appellant's Brief; see also May 2011 Rating Decision (granting service connection for diabetes mellitus on a presumptive basis due to herbicide agent exposure in service). In furtherance of this claim, the Veteran underwent a VA examination in June 2011. During the examination, he reported the onset of hypertension 10 years earlier. At that time, a private treatment provider informed him that his blood pressure readings were elevated and recommended blood pressure medication, but he refused to take it. He relayed that over the past two years, his blood pressure readings have been around 160/90. Following examination, the VA examiner confirmed the Veteran's diagnosis of hypertension. Nevertheless, in light of his lay statements, the VA examiner opined it was less likely than not his hypertension was proximately due to his diabetes because it manifested eight years prior to his diagnosis of diabetes just two years ago. Unfortunately, the VA examiner failed to address the issue of aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (holding that when adjudicating a secondary service-connection issue, it is clear error for the Board to rely on an opinion that addressed only causation). As another matter, because the Veteran's theory of entitlement that his hypertension is secondary to his presumed herbicide agent exposure in service was first raised in December 2017, the VA examiner did not have an opportunity to proffer a nexus opinion in this regard. For the reasons above, the Board finds the June 2011 Hypertension VA Examination Report is inadequate to adjudicate this claim, and a remand is necessary to obtain an addendum VA medical opinion. II. Service Connection for a Vascular Disability The Veteran contends that his has a vascular disability secondary to his service-connected diabetes. See October 2010 Statement in Support of Claim. The Veteran was afforded a VA examination in June 2011 with respect to this claim. Upon examination, the VA examiner diagnosed him with arteriosclerosis obliterans of the right upper extremity. The VA examiner went on to opine that it was less likely than not proximately due to his diabetes. Rather, the VA examiner attributed the diagnosis to his self-admitted long-term history of smoking. At the time of examination, he confirmed that he has been smoking a pack a day since the age of nine. Again, the VA examiner failed to address the issue of aggravation. See El-Amin, supra. Furthermore, the VA examiner neglected to address the findings in a July 2009 D.V.L. Upper Arterial Physiologic Study, which found decreased arterial flow and arterial occlusion in the left upper extremity as well as decreased arterial flow and small vessel disease in the right upper extremity. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Given the above, the Board finds the June 2011 Arteries, Veins, and Miscellaneous VA Examination Report is inadequate to adjudicate this claim, and a remand is necessary to obtain another VA examination. Accordingly, the case is REMANDED for the following action: 1. Obtain a copy of all the Veteran's relevant treatment records from the San Juan VAMC prior to January 20, 2012 as well as any relevant outstanding current treatment records. 2. Once the first request has been completed, to the extent possible, obtain an addendum medical opinion from an appropriate medical professional regarding the nature and etiology of the Veteran's hypertension. After reviewing the complete record, the examiner should: a. Opine as to whether it is at least as likely as not (50 percent probability or greater) caused by or otherwise related to his active duty service, to include his presumed exposure to herbicide agents, and explain why. The examiner is reminded that although hypertension is not among the diseases eligible for presumptive service connection due to herbicide agent exposure, service connection on a direct basis remains available. As such, the examiner should discuss the argument raised by the Veteran's representative in their December 2017 Appellant's Brief that the National Academy of Science's Institute of Medicine's Veterans and Agent Orange, Updates 2010 and 2012 indicate there is an association between herbicide agent exposure and hypertension. b. If his hypertension is not caused by or otherwise related to his active duty service, opine as to whether it is at least as likely as not (50 percent probability or greater) proximately due to or aggravated beyond its natural progression by his service-connected diabetes and explain why. The examiner is reminded that causation and aggravation are distinct concepts, and each must be addressed when proffering an opinion. c. In rendering an opinion, the examiner should also consider his relevant lay statements. 3. Once the first request has been completed, to the extent possible, schedule the Veteran for an examination with an appropriate medical professional to determine the nature and etiology of his claimed vascular disability. After reviewing the complete record, the examiner should: a. Identify all current and prior diagnoses of a vascular condition. b. Reconcile all prior diagnoses of a vascular condition, to include arteriosclerosis obliterans of the right upper extremity, decreased arterial flow, small vessels disease of the right upper extremity, and arterial occlusion of the left upper extremity, with the current findings. If any prior diagnosis cannot be reconciled with the current findings, explain why. c. As to each diagnosis, opine as to whether it is at least as likely as not (50 percent probability or greater) caused by or otherwise related to his service and explain why. d. As to any diagnosis that is not caused by or otherwise related to his service, opine as to whether it is at least as likely as not (50 percent probability or greater) proximately due to or aggravated beyond its natural progression by his service-connected diabetes and explain why. The examiner is reminded that causation and aggravation are distinct concepts, and each must be addressed when proffering an opinion. e. In rendering an opinion, the examiner should consider his relevant lay statements. 4. Once each of the above requests has been completed, to the extent possible, readjudicate the appeal. 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). These claims must be afforded expeditious treatment. The law requires that all claims remanded by the Board 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). _________________________________________________ L.M. BARNARD Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), 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 this appeal. 38 C.F.R. § 20.1100(b) (2017).