Citation Nr: 21071177 Decision Date: 11/30/21 Archive Date: 11/29/21 DOCKET NO. 16-41 556 DATE: November 30, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus type II, is remanded. Entitlement to service connection for kidney disease, to include as secondary to diabetes mellitus type II and/or hypertension, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from June 1966 to October 1969, with service in the Republic of Vietnam. These matters are before the Board of Veterans' Appeals (Board) on appeal from a February 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In August 2019, the Veteran testified before a Veterans Law Judge (VLJ) at a video conference hearing; however, a written transcript of the proceeding could not be produced due to technical difficulties. In November 2019, the Veteran was notified and provided the opportunity for another hearing. The Veteran and his daughter subsequently testified at a virtual tele-hearing before the undersigned VLJ in July 2021. A transcript of that hearing has been associated with the record. Unfortunately, the claims on appeal must be remanded for further development. Although the Board regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide these claims so that the Veteran is afforded every possible consideration. Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus type II, is remanded. Entitlement to service connection for kidney disease, to include as secondary to diabetes mellitus type II and/or hypertension, is remanded. The Veteran contends that his currently-diagnosed hypertension and kidney disease were incurred in or caused by military service, to include as secondary to service-connected diabetes mellitus type II. With regard to hypertension, the Veteran has alternatively argued that service connection may be warranted on a presumptive basis for chronic disease per 38 C.F.R. §§ 3.307, 3.309 because he was diagnosed with high blood pressure within one week of separation from service. With regard to kidney disease, the Veteran alternatively claims that his condition is secondary to hypertension; although the medical evidence of record supports such a finding, the Veteran is not service-connected for hypertension. In January 2015, the Veteran underwent a VA diabetes mellitus examination. Upon examination, a VA examiner confirmed that the Veteran has diagnoses of hypertension and chronic kidney disease, but stated that these conditions have been present long before the Veteran's 2014 diagnosis of diabetes mellitus. Therefore, the examiner opined that the Veteran's hypertension and kidney disease are not connected to or aggravated by diabetes. The Board finds the January 2015 opinion to be inadequate for fairly deciding the Veteran's claims. First, the examiner did not provide an etiology opinion using the correct legal standard of "at least as likely as not." Moreover, the examiner did not provide any medical rationale to support her conclusory finding that the Veteran's diabetes does not aggravate his hypertension or kidney disease. See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). Finally, the examiner did not provide an opinion addressing direct or presumptive service connection. Once VA undertakes the effort to provide an examination or opinion when developing a service connection claim, it must provide one that is adequate for the purposes of the determination being made. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In light of the above, the Board finds that remand is required to obtain an adequate medical opinion before the Board can render an informed decision on the Veteran's claims. See Douglas v. Shinseki, 23 Vet. App. 19, 26 (2009). Finally, at his July 2021 Board hearing, the Veteran testified that his hypertension and kidney disease have been previously treated by private healthcare providers. The record does not show that these relevant medical records have been requested or associated with the claims file. Therefore, on remand, the Veteran should be requested to identify any pertinent outstanding private treatment records and the RO must make appropriate efforts to obtain any identified records. Accordingly, the matters are REMANDED for the following actions: 1. Contact the Veteran and request that he provide information as to any outstanding private treatment records pertinent to his hypertension and/or kidney disease. After obtaining the necessary authorization from the Veteran, the RO must make reasonable efforts to obtain any identified outstanding records. 2. Then, obtain an addendum medical opinion from a VA examiner (M.D.) of appropriate expertise discussing the nature and etiology of the Veteran's hypertension and kidney disease. A VA examination need not be scheduled unless deemed necessary by the examiner or otherwise required by the evidence. The examiner must review the claims file in its entirety, to include a copy of this REMAND, and that review must be noted in the report. Thereafter, the examiner should provide a fully-articulated medical opinion addressing the following: Hypertension (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's hypertension was incurred in or caused by any in-service disease, event, or injury, to include exposure to herbicide agents, or manifested to a compensable degree within one year of separation? In providing a response to the above, the examiner must specifically address the Veteran's contention that he was diagnosed with high blood pressure in October 1969, just one week after separation from service. The examiner must also thoroughly review the Veteran's service treatment records and comment on the relevance, if any, of high blood pressure readings during service, to specifically include his October 1969 separation examination showing a blood pressure reading of 120/86. (b) Is it at least as likely as not (50 percent or greater probability) that the Veteran's hypertension was caused by his service-connected diabetes mellitus? (c) Is it at least as likely as not (50 percent or greater probability) that the Veteran's hypertension was aggravated by (increased in severity beyond its natural progression) his service-connected diabetes mellitus? The examiner must provide separate opinions for questions (b) and (c). Kidney Disease (d) Is it at least as likely as not (50 percent or greater probability) that the Veteran's kidney disease was incurred in or caused by any in-service disease, event, or injury, to include exposure to herbicide agents. (e) Is it at least as likely as not (50 percent or greater probability) that the Veteran's kidney disease was caused by his service-connected diabetes mellitus? (f) Is it at least as likely as not (50 percent or greater probability) that the Veteran's kidney disease was aggravated by (increased in severity beyond its natural progression) his service-connected diabetes mellitus? As above, the examiner must provide separate opinions for questions (e) and (f). In addressing the matter of aggravation, the examiner should note that it is not required that the claimed disabilities are shown to be aggravated beyond natural progression predominantly by diabetes mellitus, but rather, whether there is any contributing degree of aggravation beyond natural progression by diabetes mellitus. Additionally, aggravation under 38 C.F.R. § 3.310(b) does not require that there be permanent worsening of the nonservice-connected disability any increase in disability is sufficient. The examiner is advised that the term "at least as likely as not" does not mean "within the realm of possibility." Rather, it means that the weight of the medical evidence both for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against it. It is imperative that the requested medical opinion(s) fully address the Veteran's contentions, Board hearing testimony, service treatment records, private and VA treatment records, and any other relevant lay or medical evidence of record. The examiner is advised that the Veteran's lay contentions of record must be considered and weighed in making the determination as to whether a nexus exists between the claimed disabilities and military service. It should be noted that a lack of documented treatment for a claimed disability in service, while probative, cannot serve as the sole basis for a negative finding. The examiner must provide a complete rationale for any opinions offered, citing to the examiner's own expertise, medical principals, and/or evidence in the Veteran's record, when necessary, to support the conclusion reached. If an opinion cannot be reached without resorting to speculation, the examiner must fully explain why that is so. J. NICHOLS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Melissa Barbee, Counsel 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.