Citation Nr: 21020825 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 14-08 261 DATE: April 8, 2021 REMANDED Entitlement to an initial rating in excess of 10 percent for hypertension is remanded. REASONS FOR REMAND The Veteran served honorably on active duty from June 1989 to September 2012. This matter comes before the Board of Veterans’ Appeals (Board) from a March 2013 rating decision of the Department of Veterans Affairs (VA). This claim was remanded by the Board in a January 2018 decision in pursuit of a more current evaluation of the Veteran’s hypertension and the acquisition of emergency room records mentioned in the Veteran’s statements. In September 2020, due to the failure to obtain the emergency room records, this matter was remanded by the Board for non-compliance with the January 2018 remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). This matter is now before the Board again. Unfortunately, there has not been substantial compliance with the Board’s previous remand directives regarding the issue of entitlement to an initial rating in excess of 10 percent for hypertension. Another remand is required. Stegall, 11 Vet. App. at 271. 1. Entitlement to an initial rating in excess of 10 percent for hypertension is remanded. The Veteran contends that his blood pressure reading has increased drastically since April 2010. Specifically, the Veteran noted a February 2014 emergency room visit in San Pablo, Laguna, Philippines. The emergency room visit was initially for his swollen fingers; however, his blood pressure was elevated at 170/120 when measured. The Veteran asserts that the doctor had to prescribe him more medication to control his elevated blood pressure. See VA Form 9 (2014). In its January 2018 decision, the Board instructed the Regional Office (RO) to request the missing emergency room medical records mentioned by the Veteran. In January 2020, the RO sent VA Form 21-4142, a general release for medical provider information to the VA, to the Veteran. The Veteran completed a VA Form 21-4142, and it was received by the RO in February 2020. Although the Veteran filled out VA Form 21-4142, the RO inaccurately stated in its February 2020 supplemental statement of the case (SSOC) that it had not received the form and made no further effort to obtain the emergency room medical records. In September 2020, the Board instructed the RO to comply with the previous remand and attempt to procure the emergency room records initially sought in the prior remand. Further, the Board stated in its decision to use the completed release form (VA Form 21-4142) and attempt to procure the emergency treatment records initially sought in the January 2018 remand. In September 2020, the RO sent a subsequent development letter to the Veteran which requested clarification of the dates of the emergency room treatment and completion of another VA Form 21-4142. In the January 2021 SSOC, the RO stated that no reply from the September 2020 letter was received. The RO did not make a formal finding as to the status of the emergency treatment records. Although there is an updated December 2020 VA treatment record associated with the claim file, these VA records do not document any emergency treatments. The Veteran is advised to clarify whether his emergency room visit previously described occurred in a VA or private facility. Additionally, the Veteran is reminded that he should include the provider or facility names of any non-VA facilities in VA Form 21-4142. This includes any emergency visits that was done outside of the VA Manila facility. The Veteran is reminded that although VA has a duty to assist claimants to obtain evidence needed to substantiate a claim, the Veteran must also do his part to provide the Board with the current relevant private treatment records so that his appeal for a higher initial rating for hypertension may be properly adjudicated. Therefore, the Veteran is hereby notified that the duty to assist is a two-way-street. If the Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the relevant evidence. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, as discussed, a remand is required to allow VA to obtain the Veteran’s emergency treatment records. The matters are REMANDED for the following action: 1. Confirm with the Veteran the name and date of the emergency room he was admitted to in San Pablo, Laguna, the Republic of the Philippines, and request the emergency room records. Request the Veteran complete a VA Form 21-4142 for any relevant medical providers, to include private medical providers or facilities. If the VA Form 21-4142 received in February 2020 is no longer valid or lacks information needed by the RO to request the records, the RO should specifically state as much in a duty to assist letter to the Veteran; and that specifically identifies what information is needed and what form must be completed. Make as many requests as necessary to obtain the records. If it is determined that the records do not exist or that further attempts to obtain the records would be futile, a formal finding should be entered into the record and the Veteran should be notified and provided the opportunity to obtain and submit the evidence. 2. Upon receipt of the requested records, or the finding that such records do not exist or further attempts to obtain the records would be futile, obtain an addendum opinion from an appropriate clinician to assess the current severity of the Veteran’s hypertension. If, in the judgement of the clinician, a new examination is necessary, schedule the Veteran for an examination. (Continued on the next page)   The examiner is asked to opine whether diastolic pressure is predominately 110 or more, 120 or more, or 130 or more; and, whether systolic pressure is predominately 200 or more. A detailed explanation is required to support the opinion. A complete and thorough rationale must be provided for any opinions expressed with consideration given to all evidence of record. If the examiner is unable to offer the opinion requested, he or she must explain in detail why that is the case. If the inability to opine is due to the fact that the examiner lacks the expertise to render such an opinion, or due to the fact that some additional testing or information is needed, and possibly available, that would permit such an opinion, the examiner should clearly and specifically state so, and, if applicable, the examiner should also state precisely what additional testing or information is needed in order to render the requested opinion. Tiffany Dawson Veterans Law Judge Board of Veterans’ Appeals Law Clerk for the Board N. Jamordee 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.