Citation Nr: 20046041 Decision Date: 07/09/20 Archive Date: 07/09/20 DOCKET NO. 11-00 593 DATE: July 9, 2020 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus, type II, and/or service-connected atrial fibrillation, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1968 to June 1971. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a May 2008 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in September 2014, April 2015, and April 2016, at which times it was remanded for additional development. Also, in April 2017 and June 2018, the Board requested advisory medical opinions. The appeal has now returned to the Board. Service connection for hypertension, to include as secondary to the service-connected diabetes mellitus, type II, and/or service-connected atrial fibrillation Unfortunately, for reasons expressed immediately below, the Board finds that this appeal must be remanded once again for further development. The Board regrets the delay associated with this remand but finds that a remand is necessary to ensure that the Veteran is accorded full compliance with VA’s statutory duty to assist and to ensure that there is a full and complete record upon which to adjudicate this appeal. It appears that records which were previously associated with the claims file are now missing. In the most recent Board action, in June 2018, the Board requested clarification from a May 2017 examiner, who did not provide rationale for the opinion provided in response to the Board’s April 2017 request for a medical opinion. The April 2017 Board request for an advisory medical opinion and the corresponding May 2017 opinion are not included in the claims file. As they appear to have been associated with the claims file at the time of the June 2018 Board clarification request, and attempts to locate these missing records at the Board’s level have been unsuccessful, the RO should attempt to locate these records and re-associate them with the claims file. Attempts to locate the records and the steps taken should be documented in the claims file. Documentation of the efforts made, steps taken, and responses should be included in the record and appropriate search procedures for locating these records should be followed. If records cannot be located, the RO should contact the Veteran and his representative to allow them the opportunity to provide these records should they have retained a copy. Related to these two identifiable missing records, the Board notes that there appears to be a gap in the Veteran’s claims file, as no documents are of record between February 2017 and May 2019. The Board also notes that the most recent VA treatment records in the file are from June 2014. Any outstanding VA and private treatment records should also be obtained on remand. An independent medical opinion was obtained in response to the Board’s June 2018 request for clarification. The Board asked for clarification regarding whether the Veteran’s hypertension has been aggravated by his service-connected diabetes mellitus type II or his service-connected atrial fibrillation. Specifically, the Board directed the examiner to provide a rationale addressing the Veteran’s history, articles submitted by the Veteran, manifestations, clinical course, and character of the Veteran’s hypertension in providing an opinion. The examiner was additionally asked to address the inconsistencies of the September 2016 medical opinion which found that the current severity of the Veteran’s hypertension was higher than his baseline level, yet, at the same time, had indicated that his hypertension had not worsened over time and asked to address whether the Veteran’s hypertension has increased in severity beyond his baseline level. The May 2019 opinion did not adequately address the Board’s request for clarification, as the examiner did not provide a thorough rationale as was requested and did not address the inconsistencies from the September 2016 examination. As the provided opinion was inadequate, a remand is warranted to obtain an addendum opinion concerning the question of whether the Veteran’s hypertension has been aggravated by his service-connected diabetes mellitus type II or his service-connected atrial fibrillation. This matter is REMANDED for the following action: 1. Make appropriate efforts to locate the missing documents and records, following appropriate policies and procedures for locating missing records. In addition to attempting to locate the April 2017 request for an opinion and the corresponding May 2017 examiner’s opinion, the RO should search for records between February 2017 and May 2019 to ensure that there is a complete record before the Board. Document all actions taken and include documentation of actions in the record. If any missing records are not located, such should be documented in the record and the Veteran and his representative should be notified and allowed appropriate time to provide the missing records should they have retained a copy. 2. Identify and obtain any pertinent outstanding VA and private treatment records—to include VA treatment records since June 2014—and associate them with the claims file. All requests and responses for these records must be documented. If any identified records cannot be obtained, notify the Veteran of the missing records, the efforts taken, and any further efforts that will be made by VA to obtain such evidence, and allow him an opportunity to provide the missing records. 3. Then, forward the Veteran’s claims file to an appropriate examiner to obtain an addendum opinion as to the nature and etiology of the Veteran’s hypertension. The claims file must be made available to, and be reviewed by, the examiner. Based on a review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that the Veteran’s hypertension is etiologically related to his active service. The examiner should also opine as to whether the Veteran’s hypertension was caused, or aggravated, by his service-connected diabetes mellitus, type II or his service-connected atrial fibrillation. In answering this question, the examiner is directed to review the Informal Hearing Presentations submitted by the Veteran’s representative and the articles included in those arguments, as well as the April 2009 letter submitted by the Veteran’s private physician. The examiner is also asked to address the inconsistencies of the September 2016 as described above and address whether the Veteran’s hypertension has increased in severity beyond his baseline level. Rationale for all opinions expressed must be provided. The provided rationale should include a discussion of the accepted medical principles pertaining to the history (to include discussion of the medical articles submitted by the Veteran and his representative), manifestations, clinical course, and character of the Veteran’s hypertension. A clear explanation for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the examiner is unable to provide an opinion, he or she should explain why. If any opinion requested above cannot be provided without the benefit of an additional examination, the veteran should be provided with an additional examination. THERESA M. CATINO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Goreham The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.