Citation Nr: 18146038 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 16-59 787 DATE: October 30, 2018 REMANDED Entitlement to a compensable initial disability rating for hypertension prior to October 3, 2012, and in excess of 10 percent thereafter is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1967 to November 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from September 2015 and November 2016 rating decisions. In March 2018, the Veteran testified at a Travel Board hearing before the undersigned, and a transcript is of record. 1. Entitlement to a compensable initial disability rating for hypertension prior to October 3, 2012, and in excess of 10 percent thereafter is remanded. The Veteran essentially contends that his service-connected hypertension is more disabling than contemplated by the assigned evaluations. In his October 2015 notice of disagreement, he requested a 50 percent disabling evaluation. In a September 2017 letter, the Veteran’s representative requested that the Veteran be scheduled for an updated examination for hypertension to determine the current level of disability. During his March 2018 Board hearing, the Veteran testified that he has historically seen a private cardiologist, Dr. A.E. Reid, who has since passed away. He stated that he continued to be seen at the same practice, which records show is West Coast Cardiology Medical Group, Inc. The most recent medical records from the private cardiology group associated with the claims file are from September 2014. The Veteran also testified that he sees a private primary care physician, Dr. A. Trotter, and the most recent medical records from that practice associated with the claims file are from September 2014. The most recent VA medical records associated with the Veteran’s claims file are from May 2017. The Veteran was afforded a VA examination for hypertension in August 2015. As there is no current record of the severity of the Veteran’s hypertension, on remand, VA and private treatment records since September 2014 should be associated with the claims file. 38 C.F.R. § 3.159(c); see also Bell v. Derwinski, 2 Vet. App. 611 (1992). Additionally, on remand, the Veteran must be afforded a new VA examination to determine the nature and severity of his service-connected hypertension taking into consideration his statements, the evidence of record, and accepted medical principles. 38 C.F.R. § 3.159(c)(4). The matter is REMANDED for the following actions: 1. Contact the Veteran and afford him the opportunity to identify by name, address, and dates of treatment or examination of any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all records of treatment or examination from all the sources listed by the Veteran (VA and private facilities) which are not already on file, in particular VA records since May 2017; records from West Coast Cardiology Medical Group, Inc., since September 2014; and records from Dr. A. Trotter or any subsequent primary care physician since September 2014. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file. If any records cannot be secured, provide the required notice and opportunity to respond to the Veteran and his representative. If possible, to expedite the case, the Veteran should submit these records himself. 2. After completing the foregoing development, the Veteran should be scheduled for a VA examination to assess the current nature and severity of his service-connected hypertension. The entire claims folder and a copy of this Remand must be provided to the examiner in conjunction with the examination. The examiner is requested to review all pertinent records associated with the claims file, and the examiner must indicate on the examination report that such review was undertaken. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. All pertinent symptomatology and findings must be reported in detail in accordance with Diagnostic Code 7101. In particular, the examiner should indicate (1) the predominate readings for systolic pressure; (2) the predominate readings for diastolic pressure; and (3) whether the Veteran requires continuous medication for control of his hypertension. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. After completing the above actions and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim must be readjudicated. If the claim remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. L. CHU Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Leanne M. Innet, Associate Attorney