Citation Nr: 18155138
Decision Date: 12/04/18	Archive Date: 12/03/18

DOCKET NO. 14-04 305
DATE:	December 4, 2018
REMANDED
Entitlement to a rating in excess of 0 percent for right great toe scars is remanded.
Entitlement to a rating in excess of 0 percent for status post right foot surgery first metatarsophalangeal joint; degenerative changes of the first metatarsophalangeal joint is remanded.
Entitlement to service connection for hypertension is remanded.
REASONS FOR REMAND
Both the increased rating issues are listed on a Statement of the Case (SOC) dated in November 2013. The January 2014 VA Form 9 is unclear regarding whether the Veteran was appealing both issues. He listed only the metatarsophalangeal joint, but appears to reference the criteria for scarring and requested a new VA examination to determine the extent of his disabilities. The representative’s May 2018 Informal Hearing Presentation (IHP) listed both issues. The Board has interpreted the issues broadly and remands both issues for further development.
Compensation and Pension Record Interchange (CAPRI) documents, including VA treatment records and a March 2014 VA examination were uploaded to the electronic folder after the date of the SOC. The CAPRI documents were not submitted by the Veteran. An attempt was made to obtain waiver of Regional Office (RO) consideration via a letter sent to the Veteran in August 2018, but no response was received. With no waiver of RO consideration, these matters must be remanded for RO consideration.
The Veteran also referenced future surgery to fuse the joint on his Form 9, but the March 2014 VA examination contains no mention of this surgery having occurred. It is unclear whether this surgery occurred, where it occurred, and whether the 2014 VA examination accurately represents the Veteran’s current disability. Relevant treatment records should be obtained. A new examination may also be necessary.
In August 2015, the Veteran submitted a waiver of RO consideration for additional evidence and records that the Veteran submitted the date of the waiver (August 7, 2015). However, there are no additional documents or evidence received around August 2015 or afterwards. If relevant evidence was intended to be submitted, the Veteran should be given a chance to provide such evidence.
For hypertension, rating decisions denied hypertension in November 2011 and again in December 2011. The Veteran’s Notice of Disagreement (NOD) is listed with a receipt date in December 2011 in the electronic folder and is dated in December, no year given, with VA receipt stamps in December 2011 and March 2012. The NOD contains a sentence stating the Veteran is submitting evidence for hypertension (HTN). The file contains VA treatment records which appear to have been submitted by the Veteran in early 2012 and show high blood pressure readings. The November 2013 SOC did not address hypertension. As the NOD shows disagreement with an adjudicative determination by the AOJ regarding hypertension and a desire to contest the result (submitting evidence to substantiate the claim), it is accepted as a NOD to the November 2011 rating decision for hypertension and a SOC should be issued. 
The matters are REMANDED for the following action:
1. Contact the Veteran regarding any right foot metatarsophalangeal joint surgery. If surgery occurred at a private medical facility, request that the Veteran either provide any private treatment records or complete a release for such provider(s) and take all appropriate actions to obtain these records.
2. Notify the Veteran that no additional evidence was received along with the August 2015 waiver of RO consideration and request resubmission of any additional records or evidence he intended to submit.
3. Obtain any outstanding VA treatment records.
4. Afford the Veteran an appropriate VA examination to determine the current severity of status post right foot surgery first metatarsophalangeal joint; degenerative changes first metatarsophalangeal joint and right big toe scars.
5. Issue an Statement of the Case (SOC) for entitlement to service connection for hypertension, as the Veteran filed a timely Notice of Disagreement in December 2011.
 
H. N. SCHWARTZ
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	P. Yoffe, Associate Counsel