Citation Nr: 21073802 Decision Date: 12/10/21 Archive Date: 12/10/21 DOCKET NO. 19-03 990 DATE: December 10, 2021 REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus, and to include as due to herbicide agent exposure is remanded. Entitlement to service connection or numbness in the left foot, to include as secondary service-connected diabetes mellitus, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1968 to May 1971, to include service in the Republic of Vietnam. These matters come to the Board of Veterans' Appeals (Board) on appeal from a June 2018 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a video conference hearing before the undersigned Veterans Law Judge (VLJ) of the Board in February 2021. A transcript of the hearing has been associated with the claims file. The record was held open for 90 days following the hearing to allow for the submission of additional evidence. However, additional evidence was not received. 1. Service Connection Hypertension The Veteran seeks entitlement to service connection for hypertension. Specifically, the Veteran asserts that his hypertension was caused or aggravated by his diabetes mellitus; and in the alternative, was caused or is due to his exposure to herbicide agents during active service. See generally Board hearing testimony, February 1, 2021. The Board notes that the record establishes that the Veteran has been diagnosed with hypertension and the Veteran has verified service in the Republic of Vietnam. To date, a VA etiology opinion has not been obtained. Additionally, the Board notes that after several requests, VA has still not received the Veteran's service treatment records. The record indicates that the Veteran's service treatment records may be "lost." See e.g. Email Correspondence, October 15, 2018. In addition, it appears the Veteran's service treatment records were removed from the facility. See e.g. Email Correspondence, October 16, 2018. However, there was no formal finding of unavailability nor indication from the file that the Veteran's service treatment records are unavailable for review. In light of the foregoing, the Board concludes that the Veteran should be afforded a VA examination to determine the nature and etiology of the claimed hypertension. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); see also Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018). Moreover, the RO should again attempt to obtain and associate with the claims file the Veteran's service treatment records, and if they are unable to do so, indicate the attempts and findings of unavailability in the claims file. 2. Service Connection Numbness in the Left Foot The Board notes that in July 2018, VA received the Veteran's timely and valid Notice of Disagreement as to entitlement to service connection for numbness in the left foot. The respective statement of the case (SOC), which was issued to the Veteran in January 2019, does not address this issue. The SOC fails to address the respective claim entitlement to service connection for numbness in the left foot, even though it was identified on the notice of disagreements. Accordingly, the Veteran has never been issued a SOC as to entitlement to service connection for numbness in the left foot. As a result, this portion of the Veteran's claim is remanded. See Manlincon v. West, supra. The matter is REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. Additionally, the RO should attempt to obtain any and all service treatment records and associate them with the claims file. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in his possession. For federal records, to include service treatment records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Schedule the Veteran with an appropriate clinician(s) for a VA examination to determine the etiology of his claimed hypertension. The record, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Any indicated evaluations, studies and tests should be conducted. The need for physical examination is left to the discretion of the examiner. Thereafter, the examiner is asked to furnish an opinion with respect to the following question: (A)Is at least as likely as not (50 percent or greater probability) that the Veteran's hypertension is etiologically related to his active service, to include exposure to herbicide agents during his service in the Republic of Vietnam? (B) Is at least as likely as not (50 percent or greater probability) that the Veteran's hypertension was caused or aggravated by his service-connected diabetes mellitus? A RATIONALE FOR ALL OPINIONS EXPRESSED SHOULD BE PROVIDED. The examiner must reconcile any conflicting medical evidence of record. A clear rationale for all opinions must be provided, and a discussion of the facts and medical principles involved would be of considerable assistance. If the examiner opines that any of the above questions cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. A rationale should be provided for any opinion offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinion must support the conclusions reached with an analysis that is adequate to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. (Continued on the next page) 3. Additionally, issue the Veteran a Statement of the Case responding to the claim for entitlement to service connection for numbness of the left foot. Advise the Veteran of the time period in which to perfect his appeal. If the Veteran perfects his appeal of this issue in a timely fashion, then return the case to the Board for its review, as appropriate. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mariah Sim, 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.