Citation Nr: 18159382 Decision Date: 12/19/18 Archive Date: 12/18/18 DOCKET NO. 15-41 164A DATE: December 19, 2018 REMANDED Whether new and material evidence has been received to reopen a claim for service connection for an acquired psychiatric disorder is remanded. Whether new and material evidence has been received to reopen a claim for service connection for a left foot disorder (also characterized as calluses and osteoporosis) is remanded. Whether new and material evidence has been received to reopen a claim for service connection for a right foot disorder (also characterized as calluses, osteoporosis, right little toe cystic bone lesion, and plantar warts) is remanded. Whether new and material evidence has been received to reopen a claim for service connection for a septal infarct (now claimed as a heart disorder) is remanded. Whether new and material evidence has been received to reopen a claim for service connection for hypertension is remanded. Entitlement to service connection for diabetes mellitus is remanded. Entitlement to service connection for high cholesterol is remanded. Entitlement to service connection for a liver disorder is remanded. Entitlement to service connection for a sleep disorder, including sleep apnea, to include as secondary to an acquired psychiatric disorder, is remanded. Entitlement to service connection for tinnitus, to include as secondary to hypertension, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1980 to June 1983. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2014 rating decision of the Department of Veterans Affairs (VA). The Board has recharacterized the left and right foot claims as stated above in light of the prior adjudications of the claims and the Veteran’s contentions, as well as for clarity. In an October 1998 decision, the Board denied service connection for a right foot disorder, including consideration of the above diagnoses. See also August 1993, October 1993, and December 1995 rating decisions (agency of original jurisdiction (AOJ) considered various right foot diagnoses). In a December 1993 rating decision, the AOJ denied service connection for a left foot disorder, including consideration of the above diagnoses, and it again addressed left foot disorders in the December 1995 rating decision. See also October 1993 letter (AOJ clarified nature of appeal at that time); January 1996 letter (AOJ attempt to clarify written disagreement with December 1995 rating decision given ongoing appeal; no response from Veteran). Following the October 1998 Board decision, the AOJ declined to reopen the left and right foot osteoporosis claims prior to the current request to reopen (new claim). See December 1999 and March 2002 rating decisions. In the new claim, the Veteran broadly requested service connection for a bilateral foot disorder. The Board has also recharacterized the acquired psychiatric disorder claim more broadly for the same reasons. The Board denied the claim for an acquired psychiatric disorder in the October 1998 decision, considering multiple diagnoses. See also August 1993 and December 1995 rating decisions. Following the October 1998 Board decision, the AOJ declined to reopen the claim in July 2000 and March 2002 rating decisions. Finally, the claims for service connection for a sleep disorder and tinnitus have been recharacterized to consider entitlement on a secondary basis as raised by the record. See January 2014 VA examination report (Veteran reported tinnitus first started after taking medicine for hypertension); February 2017 private sleep apnea opinion (sleep apnea related to mental health problems). On review, the Board finds that additional development is necessary prior to final adjudication of the Veteran’s claims. Specifically, it appears that there may be outstanding VA and private treatment records, as well as Social Security Administration (SSA) records, as detailed in the directives below. The AOJ should also make an attempt to secure the Veteran’s complete service personnel records and any in-service mental health treatment records through a request for any mental health jacket, as they may be relevant to the claims. In connection with a prior appeal, the Board instructed the AOJ to secure the Veteran’s service treatment records, as they were incomplete; however, such efforts were not successful. See September 1995 3101 response; September 1995 report of contact with Reserve unit. The AOJ will also be able to verify any relevant periods of service. For example, the Veteran’s representative indicated in an August 2017 written appellate brief that an April 1984 examination (showing reported psychiatric symptoms at that time) was a separation examination from active duty and that a VA treatment record from earlier that same month (showing mental health treatment) was also a service treatment record. However, the record otherwise indicates that the Veteran separated from active duty service in 1983, and it is unclear if he had any qualifying service after that time. See, e.g., April 1984 VA treatment record (Veteran reported receiving multiple Article 15s and being barred from reenlisting); May 1993 original compensation claim; April 1994 Bd. Hrg. Tr. at 3 (representative in prior appeal indicated that Veteran joined the Reserve about a year after active duty and was given the 1984 examination). The case is REMANDED for the following actions: 1. The AOJ should: (1) contact the 377th Combat Support Hospital in Chattanooga, Tennessee (the location of the Veteran’s April 1984 Reserve examination), to attempt to locate any additional active duty and Reserve service treatment records; and (2) secure the Veteran’s complete service personnel records from his active duty service, including any DD 214s, as well as any in-service records of mental health treatment and evaluations (mental health jacket). The AOJ should also verify any relevant period of service if necessary. In particular, the AOJ should determine whether the Veteran had any service after June 1983. All attempts and responses should be documented in the claims file. 2. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his claimed disorders. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. A specific request should be made for any non-VA treatment, including from Memorial North Park Family and Internal Medicine. See January 2014 written statements (Veteran identified doctor at that facility as his treatment provider since mid-2009). The AOJ should also secure any outstanding VA treatment records, including: (1) any treatment records from the Murfreesboro/Alvin C. York VA Medical Center (VAMC) dated from 1980 to 1983 and from April 1993 to May 1993. See, e.g., January 2014 written statement on VA Form 21-4142 (Veteran reported twice-weekly drug and alcohol treatment at that facility during service); June 7, 1993, AOJ request for records from that facility and Chattanooga VA Outpatient Clinic treatment records dated around that time (indicate Veteran was admitted to Murfreesboro VAMC from April 1993 to May 1993; unclear if any records from that facility for those dates are available). (2) more recent treatment records. See, e.g., September 2013 formal application (Veteran reported ongoing VA treatment, including for new claims; claims file contains limited recent records); February 2017 private mental health evaluation (noted review of VA treatment records dated from 2014 to 2016). 3. The AOJ should obtain a copy of any decision to grant or deny SSA disability benefits to the Veteran and the records upon which that decision was based and associate them with the claims file. If the search for such records has negative results, the claims file should be properly documented as to the unavailability of those records. See, e.g., January 2014 written statement (Veteran reported being granted SSA disability benefits for schizophrenia in 1999). 4. After completing the above actions, the AOJ should conduct any other indicated development. Further development may include providing a VA examination or obtaining a VA medical opinion, including for any reopened claim and/or the disorders claimed on a secondary basis if service connection is established for the underlying disorder. See also VA examination reports from 1993 (mental health and feet) and 2014 (tinnitus); February 2017 private evaluation (mental health); February 2017 private opinion (sleep apnea). J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Postek, Counsel