Citation Nr: 9924596 Decision Date: 08/30/99 Archive Date: 09/08/99 DOCKET NO. 96-03 129 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Wilmington, Delaware THE ISSUES Entitlement to secondary service connection for hypertension. Entitlement to an increased evaluation for a kidney condition, currently rated as 20 percent disabling. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. WITNESSES AT HEARING ON APPEAL The veteran and her husband ATTORNEY FOR THE BOARD Richard V. Chamberlain, Counsel INTRODUCTION The veteran had active service from May 1952 to June 1954. This appeal came to the Board of Veterans' Appeals (Board) from a June 1995 RO rating decision that denied an increased evaluation for right nephroptosis postoperative nephropexy, uretero-pelvic obstruction, and pseudomembranous trigonitis (rated 20 percent). In August 1998, the Board remanded the case to the RO for additional action. A February 1999 RO rating decision denied service connection for hypertension secondary to the service-connected kidney condition, and the veteran appealed. The issues now for appellate consideration are listed on the first page of this remand. REMAND A report from Craig N. Bash, M.D., neuroradiologist, dated in June 1998 notes that the veteran had hypertension that was likely secondary to renal/renin hypertension and that this latter diagnosis could not be disassociated from her service- connected disability. A report from Dr. Bash dated in September 1998 is to the effect that the etiology of the veteran's hypertension is unknown. Dr. Bash noted that the veteran needed to have a full work-up of her increased blood pressure to include renin levels and a nuclear medicine renal hypertension scan in order to definitively diagnose a renal source for her hypertension. The veteran underwent a VA compensation examination in December 1998 in order to determine the nature and extent of any hypertension and to obtain an opinion as to the etiology of any hypertension found, including any relationship to the service-connected kidney condition. The examiner reviewed the veteran's medical records and noted that she had hypertension of recent onset that did not appear related to her previous renal problems. The examiner noted that a CT (computed tomography) scan revealed a plaque in the left renal artery and recommend her for a nephrology evaluation to rule out a relationship between the hypertension and the left renal artery plaque. In February 1999, the veteran's medical records were reviewed by a VA physician. The reviewer agreed with the physician who conducted the December 1998 VA examination and concluded that the veteran's hypertension was of recent onset. The physician noted that hypertension occurring in a patient in the sixth decade of life was much more likely primary hypertension of unknown cause. The reviewer recommended the veteran for nephrology evaluation in order to determine the current severity of her kidney condition and to determine the role of the calcified plaque in the left renal artery with regard to the hypertension. In a written argument dated in August 1999, the representative requested another remand of this case to the RO for a nephrology evaluation of the veteran to include blood renin levels and any other indicated tests as recommended by various physicians prior to appellate consideration of the claims. The United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (hereinafter, the Court) has held that the duty to assist the veteran in obtaining and developing available facts and medical records included additional VA examination by a specialist, when recommended. Hyder v. Derwinski, 1 Vet. App. 221 (1991). In view of the above, the case is REMANDED to the RO for the following actions: 1. The veteran should be scheduled for a nephrology examination to determine the nature and extent of her kidney condition, and to obtain an opinion as to the etiology of her hypertension. All indicated studies should be obtained and all clinical findings reported in detail. The examiner should give a fully reasoned opinion on the etiology of the veteran's hypertension, including an opinion as to whether it is as likely as not that the service-connected kidney condition caused the hypertension. The examiner should support his or her opinion by discussing medical principles as applied to the specific medical evidence in the veteran's case. The claims folder should be made available to the examiner for review in conjunction with the examination, and the examiner should acknowledge such review in the examination report. 2. After the above development, the RO should review the claims. If action remains adverse to the veteran, she and her representative should be provided with an appropriate supplemental statement of the case. The veteran and her representative should be afforded an opportunity to respond to the supplemental statement of the case before the file is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. J. E. Day Member, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 1991 & Supp. 1999), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1998). The Board does not order or require invasive medical tests or procedures. Dr. Bash has suggested a "nuclear medicine renal hypertension scan." The examining physician may find that such a test is not necessary or indicated, or the veteran may not consent. In either event, the reasons for not conducting the scan should simply be recorded in the examination report