Source: https://veteranclaims.wordpress.com/2014/05/05/single-judge-application-cf-romanowsky-v-shinseki-26-vet-app-289-294-2013-recent-diagnosis-must-be-considered/
Timestamp: 2017-07-21 04:47:37
Document Index: 234541129

Matched Legal Cases: ['§ 7252', '§ 3', '§ 3', '§ 3', '§ 7261', '§ 7104', '§ 3', '§ 5103', '§ 3', '§ 7261', '§ 5103', '§ 3', '§ 3', '§ 3', '§ 3']

Single Judge Application, cf. Romanowsky v. Shinseki, 26 Vet.App. 289, 294 (2013); Recent Diagnosis Must be Considered | Veteranclaims's Blog
Single Judge Application, cf. Romanowsky v. Shinseki, 26 Vet.App. 289, 294 (2013); Recent Diagnosis Must be Considered	Filed under: Uncategorized — Tags: 26 Vet.App. 289, 294 (2013); Recent Diagnosis Must be Considered, cf. Romanowsky v. Shinseki, Single Judge Application — veteranclaims @ 2:04 pm Excerpt from decision below:
“The requirement that a claimant have a current disability before service connection may be granted “is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim.” McClain v. Nicholson, 21 Vet.App. 319, 321 (2007); cf. Romanowsky v. Shinseki, 26 Vet.App. 289, 294 (2013) (the Board must consider evidence of a “recent” diagnosis made prior to the filing of a claim).
United States Court of Appealsfor Veterans Claims
Chief JudgeBruce E. Kasold Clerk of the CourtGregory O. Block
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. 13-0905 Cartagena-VazquezF_13-905.pdf
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Designated for electronic publication only UNITED STATES COURT OF APPEALS FOR VETERANS CLAIMS NO. 13-0905 FELIPE CARTAGENA-VAZQUEZ, APPELLANT, V. ERIC K. SHINSEKI, SECRETARY OF VETERANS AFFAIRS, APPELLEE. Before BARTLEY, Judge. MEMORANDUM DECISION Note: Pursuant to U.S. Vet. App. R. 30(a), this action may not be cited as precedent. BARTLEY, Judge: Veteran Felipe Cartagena-Vazquez appeals through counsel a March 7, 2013, Board of Veterans’ Appeals (Board) decision denying service connection for (1) an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD) and depressive disorder; and (2) arterial hypertension, to include as secondary to exposure to herbicides or type II diabetes mellitus. Record (R.) at 3-29.1 This appeal is timely and the Court has jurisdiction to review the Board’s decision pursuant to 38 U.S.C. §§ 7252(a) and 7266(a). Single- judge disposition is appropriate in this case. See Frankel v. Derwinski, 1 Vet.App. 23, 25-26 ( 1990). For the reasons that follow, the Court will set aside the appealed portions of the March 2013 Board decision and remand those matters for further development, if necessary, and readjudication consistent with this decision. The Board also denied service connection for type II diabetes mellitus secondary to exposure to herbicides. R. at 23-28. Because Mr. Cartagena-Vazquez makes no argument with respect to that claim, the Court will not address it. See DeLisio v. Shinseki, 25 Vet.App. 45, 47 (2011) (Court’s disposition of case addressed only those portions of the Board decision argued on appeal). 1
I. FACTS Mr. Cartagena-Vazquez served on active duty in the U.S. Army from June 1969 to June 1971, including service in Vietnam. R. at 1102-03. He also served for 22 years in the Army National Guard. R. at 868, 913-14, 945-46. National Guard medical records indicate that in October 2000 he was treated for high blood pressure (R. at 1039), and in November 2000 he was taking medication for hypertension (R. at 1086). In September 2005, Mr. Cartagena-Vazquez sought VA treatment for depression and was screened as positive for PTSD. R. at 917. Later that month, he was seen at a VA mental health clinic and complained of depression, lack of interest, insomnia, frequent crying spells, suicidal ideation, poor appetite, and intrusive memories and flashbacks of combat experiences in Vietnam. R. at 913. A VA psychiatrist performed a mental status examination and, under the heading “Initial DSM-IV Diagnosis,”2 listed “Anxiety Disorder: PTSD, chronic, NOS (Not Otherwise Specified),” and “Depressive Disorder: Major Depression, NOS.” R. at 915. In March 2006, Mr. Cartagena-Vazquez filed a claim for service connection for, inter alia, a nervous condition and hypertension. R. at 971-84. In June 2006, he submitted an untranslated certificate of psychiatric treatment prepared by his private physician, Dr. Margarita Vargas López. R. at 925. That document, which was translated in March 2011, stated that Dr. Vargas López had treated the veteran since March 2006 and had diagnosed PTSD and severe major depression. R. at 187-90. Mr. Cartagena-Vazquez also submitted a VA Form 21-4142 authorizing VA to obtain additional medical records from Dr. Vargas López. R. at 923-24. In June 2006, Mr. Cartagena-Vazquez underwent a VA hypertension examination and was diagnosed with arterial hypertension. R. at 933. The examiner noted that the veteran was first diagnosed with hypertension at some point in 2000. R. at 932. InJuly2006,Mr.Cartagena-VazquezhadanotherpositivePTSD screening. R. at1848. Yet, at a January 2007 VA PTSD examination, the veteran did not report any stressors that he found “particularly traumatic” and the examiner concluded that he did not meet the DSM-IV criteria for 2 DSM-IV is a common abbreviation for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. 2
diagnosing PTSD. R. at 871, 875. Instead, the examiner diagnosed only depressive disorder, NOS. R. at 875. In February 2007, a VA regional office denied service connection for PTSD, depressive disorder, and hypertension, among other conditions. R. at 853-59. Mr. Cartagena-Vazquez filed a timely Notice of Disagreement as to that decision (R. at 850) and subsequently perfected his appeal to the Board (R. at 821-22). In the meantime, Dr. Vargas López sent the Social SecurityAdministration a summaryof the psychiatric treatment that she had provided to Mr. Cartagena-Vazquez. R. at 563-67. The summary included the following notation: “Diagnosis (DSM III or IV): (1) Major Depression Severe with Psychotic features, (2) PTSD.” R. at 567. While his claim was pendingbefore the Board, Mr. Cartagena-Vazquez continued to receive psychiatric treatment from VA. Relevant to this appeal, in April 2007, a VA psychologist indicated that the veteran “described several incidents in [Vietnam] in which his life was threatened and in which he saw atrocities that still bother him.” R. at 805. The “initial DSM-IV diagnosis” was PTSD, and the psychologist opined: “[The veteran] seems to have had PTSD and alcohol abuse problems upon his return from [Vietnam]. He was able to deal[] with his problems and become [employed] and stay employed for 30 years. Upon retirement and military activation of his son to go to Iraq, PTSD in the [patient] also appears to have reactivated.” R. at 807 ( capitalization altered). VA treatment notes from June, October, and December 2007 also indicate that the veteran “continues with depression and anxiety related to experiences in [Vietnam].” R. at 801, 1704, 1709. In April 2012, the Board remanded Mr. Cartagena-Vazquez’s claims for service connection for hypertension and an acquired psychiatric disorder, to include PTSD and depressive disorder. R. at 175-86. The Board found that additional VA medical examinations were necessary because the June 2006 VA hypertension and January 2007 PTSD examinations did not contain opinions as to the etiology of those conditions. R. at 179. The Board also found that “VA outpatient records indicate the [v]eteran has been diagnosed with chronic PTSD (see September 2005 VA outpatient note),” major depressive disorder, and depressive disorder, and the Board noted that, during the pendency of the appeal, the regulations governing service connection for PTSD had been amended. R. at 177-78. Accordingly, the Board ordered further development of those claims, including to 3
“[p]rovide the [v]eteran with notice of the amended PTSD regulations and the new requirements for substantiating a claim for PTSD,” to “[o]btain and associate with the claims file any updated VA treatment records,” and to provide him with VA psychiatric and hypertension examinations. R. at 180-85. Later in April 2012, the Appeals Management Center (AMC) sent Mr. Cartagena-Vazquez a letter, which informed him of the general requirements for establishing service connection for PTSD but did not discuss the amendments to 38 C.F.R. § 3.304(f)(3), including the addition of a provision regarding PTSD based on fear of hostile military or terrorist activity. See R. at 167-74. Thenext month,Mr.Cartagena- VazquezunderwenttheorderedVApsychiatricexamination. R. at 131-46. In response to the question “Does the [v]eteran have a diagnosis of PTSD that conforms to DSM-IV criteria based on today’s evaluation?”, the examiner marked the box for “Yes.” R. at 131. The examiner also left blank all of the boxes following the instruction, “If no diagnosis of PTSD, check all that apply.” Id. However, the only Axis I diagnosis3 the examiner listed under the section entitled “Current Diagnoses” was major depressive disorder (R. at 132), apparently because the veteran did not display three or more indicators of persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (DSM-IV criterion C for diagnosing PTSD) and two or more persistent symptoms of increased arousal ( DSM-IV criterion D for diagnosing PTSD) (R. at 138). The examiner opined that the veteran’s major depressive disorder was less likely than not incurred in or caused by service because: There is no temporal association between Major Depressive onset and military stressors. Veteran sought formal psychiatric treatment in 2006, almost thirty years after discharge from active dutyin 1971. Furthermore, there is no evidence of mental symptoms causing social or occupational impairment throughout the years after his return from the Vietnam war. He was able to hold a stable family nucleus and employment until he retired . . . after being eligible [for retirement] for duration of work in 2000. R. at 144. The DSM–IV uses a multiaxial system for classifying mental disorders. See DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 27-36 (4th ed., text revision 2000). Axis I refers to clinical disorders and other conditions that may be a focus of clinical attention. Id. at 27-28. 3 4
Also in May 2012, Mr. Cartagena-Vazquez underwent a VA hypertension examination. R. at 85-88, 147-49. The examiner noted that the veteran was diagnosed with hypertension in 1998 or 1999, had been taking oral medication for that condition ever since, and was currently “being followed by a private cardiologist who has continued his treatment.” R. at 147-48; see also R. at 773-75(September2007blood pressuretest resultsordered byprivate physician Ralph C. Conaway- Lanuza); R. at 790, 808, 867 (VA treatment notes indicating that a private physician was treating the veteran for hypertension). The examiner opined that hypertension was less likely than not incurred in or caused by service because the veteran developed hypertension many years after service and “[a]ll the blood pressure readings taken during service [were] normal.” R. at 86. In March 2013, the Board issued the decision currently on appeal. R. at 3- 29. As an initial matter, the Board found that VA had satisfied its duties to notify and to assist the veteran and no further action was required before adjudicating the appeal. R. at 4, 6-8. Turning to the merits of the claims, the Board found that the record did not contain a diagnosis of PTSD that complied with the DSM-IV because none of the private or VA medical records diagnosing PTSD were “supported by any actual recordation of test results or indications that the DSM-IV criteria were in fact[] applied and met.” R. at 14. The Board emphasized that the January 2007 and May 2012 VA medical examiners “utilized and applied” the DSM-IV criteria and determined that a diagnosis of PTSD was not warranted. R. at 15. The Board also noted that “no psychiatric disorder diagnosed post-service, to includedepression, hasbeenetiologicallylinkedto the[v]eteran’s periodofserviceoranyincident therein,” highlighting the May 2012 negative linkage opinion. R. at 16-17. The Board therefore denied service connection for an acquired psychiatric disorder, to include PTSD and depressive disorder. R. at 15-16, 18-19. Regarding hypertension, the Board found that the record did not contain evidence of hypertension in service or manifestation to a compensable degree within one year of separation from service. R. at 24-25. The Board also determined that there was no competent evidence providing linkage between hypertension and service and denied the veteran’s claim for service connection for hypertension. R. at 25-26, 29. This appeal followed. 5
II. ANALYSIS A. Service Connection for an Acquired Psychiatric Disorder Mr. Cartagena-Vazquez argues that the Board clearly erred in finding that the record does not contain a current diagnosis of PTSD that complies with the DSM-IV, or, in the alternative, that the Board provided inadequate reasons or bases to support that finding. Appellant’s Brief (Br.) at 7-15. He also contends that the Board provided inadequate reasons or bases for its finding that VA satisfied its duties to notify and to assist because VA did not provide the veteran with adequate notice of the amendments to § 3.304(f) in accordance with the April 2012 Board remand order, did not attemptto obtain the private medical records from Dr. VargasLópez, andprovidedaninadequate VA psychiatric examination in May 2012. Id. at 15-18, 20-25. The Secretary concedes that remand of the claim for service connection for an acquired psychiatric disorder is warranted because the Board did not address the April 2007 VA psychology note reflecting an initial DSM-IV diagnosis of PTSD or the June, October, and December 2007 VA psychology notes indicating a relationship between depressive disorder and service. Secretary’s Br. at 9-11, 14-15. However, the Secretary asserts that the May 2012 VA psychiatric examination was adequate (id. at 11-14) and, although “it does not appear that VA requested . . . treatment records from Dr. [Vargas] López or provide notice to [the veteran] with respect [ to] attempts to obtain these records,”that error is harmless because the record contains a summaryof her treatment of theveteran (id. at 17). It does not appear that the Secretary responded to the veteran’s notice argument. In his reply brief, Mr. Cartagena-Vazquez argues that the Court should reverse, not remand, the Board’s finding that the record does not contain a PTSD diagnosis made in accordance with the DSM-IV criteria. Reply Br. at 1-2. He also asserts that, to the extent that the Secretary failed to respond to his specific arguments regarding the adequacy of the May 2012 VA psychiatric examination and the AMC’s April 2012 notice letter, those issues should be deemed conceded and resolved in his favor. Id. at 5-7 (citing MacWhorter v. Derwinski, 2 Vet. App. 655, 656 (1992) (“[T]he Court has the authority to deem the Secretary’s failure to file an appropriate response a concession of error.”)). The Court will address the veteran’s arguments in turn. 6
1. PTSD Diagnosis Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Hickson v. West, 12 Vet.App. 247, 253 (1999). Because “Congress specifically limit[ed] entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability,” “there can be no valid claim” for service connection “[i]n the absence of proof of a present disability.” Brammer v. Derwinski, 3 Vet.App. 223, 225 (1992); see Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997) (“The statutes governing payment of benefits for disability . . . only allow payment for disability existing on and after the date of application.”). The requirement that a claimant have a current disability before service connection may be granted “is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim.” McClain v. Nicholson, 21 Vet.App. 319, 321 (2007); cf. Romanowsky v. Shinseki, 26 Vet.App. 289, 294 (2013) (the Board must consider evidence of a “recent” diagnosis made prior to the filing of a claim). For claims for service connection for PTSD, the current disability requirement must be proven with evidence diagnosing the condition in accordance with the DSM-IV. See 38 C.F.R. §§ 3.304(f), 4.125(a) (2013). “[A] clear (that is, unequivocal) PTSD diagnosis by a mental-health professional must be presumed (unless evidence shows to the contrary) to have been made in accordance with the applicable DSM criteria as to both the adequacy of the symptomatology and the sufficiency of the stressor” because “[m]ental health professionals are experts and are presumed to know the DSM requirements applicable to their practice and to have taken them into account in providing a PTSD diagnosis.” Cohen v. Brown, 10 Vet.App. 128, 140 (1997). The Board’s determination that a claimant does or does not have a current disability is a finding of fact subject to the “clearly erroneous” standard of review set forth in 38 U.S.C. § 7261(a)(4). See McClain, 21 Vet.App. at 321-22. “A factual finding ‘is “ clearly erroneous” when although there is evidence to support it, the reviewing court on the entire evidence is left with the definite and firm conviction that a mistake has been committed.'” Hersey v. Derwinski, 2 Vet.App. 7
91, 94 (1992) (quoting United States v. U.S. Gypsum Co., 333 U.S. 364, 395 (1948)). As with any finding on a material issue of fact and law presented on the record, the Board must support that determination with an adequate statement of reasons or bases that enables the claimant to understand the precise basis for that determination and facilitates review in this Court. 38 U.S.C. § 7104(d)(1); Gilbert v. Derwinski, 1 Vet.App. 49, 52 (1990). The record in this case contains numerous PTSD diagnoses made by mental health professionals, many of which expressly cite the DSM-IV. R. at 915 (September 2005 “initial DSM-IV diagnosis” of PTSD made bya VA clinical social worker), 187 (June 2006 PTSD diagnosis made by Dr. Vargas López), 567 (March 2007 “Diagnosis (DSM III or IV)” of PTSD made by Dr. Vargas López), 807 (April 2007 “initial DSM-IV diagnosis” of PTSD made by a VA psychologist). The only reason that the Board gave for rejecting the September 2005 and June 2006 PTSD diagnoses was that they were not accompanied by “actual recordation of test results or indications that the DSM-IV criteria were in fact[] applied and met.” R. at 14. However, the Board did not acknowledge that the September 2005 diagnosis explicitly referenced the DSM-IV, nor did it explain why the presumption that those diagnoses were rendered in accordance with the DSM-IV did not apply. See Cohen, 10 Vet.App. at 140. Moreover, the Board appears to have completely overlooked the March and April 2007 PTSD diagnoses, both of which referenced the DSM-IV. See R. at 14 (Board discussed only the September 2005, June 2006, and February 2008 PTSD diagnoses).4 The Board’s failure to address the Cohen presumption and its failure to account for the PTSD diagnoses of record both constitute error. See Cohen, 10 Vet.App. at 143-45 (Board errs when it “summarily reject[s] diagnoses of PTSD” and does not rely on independent medical evidence as to why those diagnoses did not comply with the DSM-IV); Caluza v. Brown, 7 Vet.App. 498, 506 ( 1995) (Board errs when it fails to account for any material evidence favorable to the claimant). Having concluded that the Board erred in its treatment of the PTSD diagnoses of record, the question remains as to the proper remedy for that error. Although Mr. Cartagena-Vazquez argues for reversal of the Board’s finding that the record does not contain a PTSD diagnosis made in accordance with the DSM-IV, the Court agrees with the Secretary that remand, not reversal, is 4 The record of proceedings does not contain a February 2008 medical record diagnosing PTSD. 8
warranted because there is more than one permissible view of the evidence of record. See Gutierrez v. Principi, 19 Vet.App. 1, 10 (2004) (“[R]eversal is the appropriate remedy when the only permissible view of the evidence is contrary to the Board’s decision.”). Specifically, the record contains conflicting medical evidence as to whether the veteran has PTSD, compare R. at 187, 567, 807, 915 (diagnoses of PTSD), with R. at 131-46, 865-76 (VA psychiatric examinations finding that the veteran did not meet the DSM-IV diagnostic criteria for PTSD), and the Board, not the Court, is the entity best positioned to evaluate that evidence and apply the Cohen presumption, see Smith v. Shinseki, 24 Vet.App. 40, 48 (2010) (“The Board, not the Court, is responsible for assessing the credibility and weight to be given to evidence.”). Therefore, the Court concludes that remand is the appropriate remedy in this case. See Tucker v. West, 11 Vet.App. 369, 374 ( 1998) (holding that remand is the appropriate remedy”where the Board has incorrectlyapplied the law, failed to provide an adequate statement of reasons or bases for its determinations, or where the record is otherwise inadequate”); see also Deloach v. Shinseki, 704 F.3d 1370, 1380 (Fed. Cir. 2013) (explaining that reversal is appropriate only”where the Board has performed the necessaryfactfinding and explicitly weighed the evidence” and this Court, based “on the entire evidence, . . . is left with the definite and firm conviction that a mistake has been committed”). 2. Etiology of Depressive Disorder To the extent that the Board separately adjudicated the PTSD and depressive disorder portions of the veteran’s claim for service connection for an acquired psychiatric disorder (see R. at 13-19, 29), the parties agree that the Board also erred in denying service connection for an acquired psychiatric disorder other than PTSD because it failed to consider and discuss VA treatment notes from June, October, and December 2007 indicating that the veteran’s depression and anxiety are “related to experiences in [Vietnam]” (R. at 801, 1704, 1709). See Secretary’s Br. at 14-15; Reply Br. at 1-2. The Court agrees that the Board erred in not addressing that evidence, see Caluza, supra, and that remand of that portion of the veteran’s claim for service connection for an acquired psychiatric disorder is also warranted, see Tucker, supra. 3. VA’s Duties To Notify and To Assist Although the Court has already concluded that remand is warranted for the Board to readjudicate all aspects of the veteran’s claim for service connection for an acquired psychiatric 9
disorder, the Court will, for the sake of guidance on remand, address Mr. Cartagena-Vazquez’s additional duty-to-notify and duty-to-assist arguments with respect to that claim. See Quirin v. Shinseki, 22 Vet.App. 390, 396 (2009) (holding that, to provide guidance to the Board, the Court may address an appellant’s other arguments after determining that remand is warranted). Specifically, the veteran asserts that the Board erred in finding that VA satisfied its duties to notify and assist because (1) VA did not adequately notify him of the amendments to § 3.304(f) in accordance with the April 2012 Board remand order; (2) VA did not attempt to obtain the private medical records from Dr. Vargas López; and (3) the May 2012 VA psychiatric examination was inadequate. Appellant’s Br. at 15-18, 20-25. These arguments are persuasive. First, although the April 2012 Board remand directed the AMC to “[p]rovide the [v]eteran with notice of the amended PTSD regulations and the new requirements for substantiating a claim for PTSD” (R. at 180), the AMC’s letter to Mr. Cartagena-Vazquez later that month did not mention those amendments or inform him about the new rule (see R. at 167-74). The notice that the AMC provided was therefore deficient because it contravened the terms of the April 2012 Board remand order. See Stegall v. West, 11 Vet.App. 268, 271 (1998) (holding that the Board errs when it fails to ensure compliance with the terms of a prior remand). Second, as the Secretary concedes (see Secretary’s Br. at 17), the record of proceedings does not reflect that VA attempted to obtain private psychiatric treatment records from Dr. Vargas López, even though the veteran adequately identified those records and authorized VA to do so (R. at 923- 24). The Secretary’s duty to assist includes making “reasonable efforts to obtain relevant private records that the claimant adequately identifies,” and, if those records are unavailable, to notify the claimant of their unavailability. 38 U.S.C. § 5103A(b)(1)-(2); 38 C.F.R. § 3.159(c) (2013); see Loving v. Nicholson, 19 Vet.App. 96, 102 (2005). VA did not undertake either action in this case, and, contrary to the Secretary’s contention (see Secretary’s Br. at 17-18), that error is not harmless because records of Dr. Vargas López’s treatment of the veteran maycontain evidence relevant to the veteran’s claim. See 38 U.S.C. § 7261(b)(2) (requiring the Court to “take due account of the rule of prejudicial error”). Finally, contrary to the Board’s finding, the May 2012 VA psychiatric examination is inadequate because it contains seemingly contradictory information as to whether the veteran has 10
PTSD. Specifically, the examiner found both that the veteran had “a diagnosis of PTSD that conforms to DSM-IV criteria based on [that] evaluation” (R. at 131) and that he did not meet the DSM-IV criteria for diagnosing PTSD (R. at 138). This internal inconsistency prevents the Board from being sufficiently informed as to whether the examiner was diagnosing PTSD in accordance with the DSM-IV and the Board erred in relying on that equivocal examination report in denying the veteran’s claim. See Stefl v. Nicholson, 21 Vet.App. 120, 123 (2007) ( holding that a VA medical examination is adequate “where it is based upon consideration of the veteran’s prior medical history and examinations and also describes the disability . . . in sufficient detail so that the Board’s ‘evaluation of the claimed disability will be a fully informed one'” ( quoting Ardison v. Brown, 6 Vet.App. 405, 407 (1994))); Green v. Derwinski, 1 Vet.App. 121, 124 ( 1991); see Monzingo v. Shinseki, 26 Vet.App. 97, 105 (2012) (explaining that medical examination report or opinion must “sufficientlyinformtheBoardofa medical expert’s judgment on a medical question and the essential rationale for that opinion”); Nieves-Rodriguez v. Peake, 22 Vet.App. 295, 301 (2008) (“[A] medical examination report must contain not onlyclear conclusions with supporting data, but also a reasoned medical explanation connecting the two.”). In light of the foregoing, the Court concludes that the Board committed clear error in finding that VA satisfied its duties to notify and to assist Mr. Cartagena-Vazquez with respect to his claim for service connection for an acquired psychiatric disorder. See Garrison v. Nicholson, 494 F.3d 1366, 1370 (Fed. Cir. 2007) (Court reviews the Board’s factual determination that VA satisfied its duty to notify under the “clearly erroneous” standard of review); Nolen v. Gober, 14 Vet.App. 183, 184 (2000) (same standard of review for the Board’s duty-to-assist determination). These errors further justify remand of that claim. See Tucker, supra. On remand, unless the Board decides to grant service connection, the Board must provide Mr. Cartagena-Vazquez with notice of the PTSD regulations applicable to his claim in accordance with the April 2012 Board remand, see Stegall, 11 Vet.App. at 271, and a new VA medical examination that clearly and unequivocally lists his current psychiatric diagnoses and opines as to whether any diagnosed condition is as likely as not related to service, see Barr v. Nicholson, 21 Vet.App. 303, 311 (2007) (“[ O]nce the Secretary undertakes the effort to provide an examination when developing a service- connection claim . . . , 11
he must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided.”). B. Hypertension Mr. Cartagena-Vazquez argues that the Board erred in finding that VA satisfied its duty to assist him in developing the claim for service connection for hypertension because VA did not attempt to obtain private hypertension treatment records. Appellant’s Br. at 16-17; Reply Br. 2-3. He also contends that the May 2012 VA hypertension examination is inadequate, and the Board therefore erred in relying on it, because “the examiner based his opinion regarding incurrence solely on the fact that high blood pressure did not develop until many years after service.” Appellant’s Br. at 20; see Reply Br. 3-4. The Secretary responds that VA was not obligated to attempt to obtain private hypertension treatment records because Mr. Cartagena-Vazquez did not adequately identify those records or authorize VA to obtain them. Secretary’s Br. at 18-20. He also asserts that the May 2012 VA hypertension examination is adequate because it is based on a review of the veteran’s records and is supported by an adequate rationale. Id. at 20-22. The Court is persuaded by the veteran’s first argument but not his second argument. As explained above, the Secretary’s duty to assist includes making reasonable efforts to obtain relevant medical records, including records from private medical professionals, as long as the claimant adequately identifies those records and authorizes the Secretary to obtain them. 38 U.S.C. § 5103A(b)(1); see Loving, supra; 38 C.F.R. § 3.159(c)(1), (3). If VA becomes aware of the existence of relevant records before deciding the claim, VA will notify the claimant of the records and request that the claimant provide a release for the records. If the claimant does not provide any necessary release of the relevant records that VA is unable to obtain, VA will request that the claimant obtain the records and provide them to VA. 38 C.F.R. § 3.159(e)(2) (2013); see Solomon v. Brown, 6 Vet.App. 396, 401 ( 1994) (“[W]here the VA is on notice that records supporting an appellant’s claim may exist, the VA has a duty to assist the appellant to locate and obtain these records.”); Ivey v. Derwinski, 2 Vet.App. 320, 323 (1992) (holding that evidence of record before VA may “raise[] enough notice of pertinent private medical records to trigger the duty to assist”). 12
VAtreatmentnotesreflectthat,onseveraloccasions,Mr.Cartagena-Vazquez reportedto VA medical professionals that he was being treated for hypertension by a private physician. R. at 148, 790, 808, 867. Other documents of record and in VA’s possession identify that physician as Dr. Ralph C. Conaway-Lanuza. R. at 773-75. Although the Secretary is correct that the record does not contain a signed VA Form 21-4142 authorizing VA to obtain private medical records from Dr. Conaway-Lanuza (see Secretary’s Br. at 19-20), the duty to assist required VA, once it was put on notice that relevant private records from Dr. Conaway-Lanuza had not been associated with the claims file, to inform the veteran that those records were outstanding and to request that he complete the necessary form authorizing VA to obtain those records. See 38 C.F.R. § 3.159(e)(2); see also Solomon and Ivey, both supra. Because VA failed to do so, the Court concludes that the Board’s finding that VA satisfied its duty to assist Mr.Cartagena-Vazquez in developinghisclaimforservice connection for hypertension is clearly erroneous, and remand is warranted on that basis. See Nolen and Tucker, both supra. Even though that claim is being remanded, the Court will nevertheless address the veteran’s additional argument regarding the adequacy of the May 2012 VA hypertension examination so that the Board will know whether it is permitted to rely on the results of that examination on remand. See Quirin, 22 Vet.App. at 396. Specifically, Mr. Cartagena-Vazquez challenges the adequacy of that examination on the groundthattheexaminerdid not provide an adequate explanation for finding that the veteran’s hypertension was not incurred in service. Appellant’s Br. at 20. However, the examiner reviewed the claims file, including the veteran’s service medical records, and noted that Mr. Cartagena-Vazquez was first diagnosed with hypertension years after service in 1998 or 1999 and “all the blood pressure readings taken during service [were] normal.” R. at 86. He also considered whether hypertension was secondary to any other potentially service- connected condition and determined that it was not. Id. This is a permissible basis for finding that the veteran’s hypertension was not incurred in service, and it is supported by reasoning that is sufficiently detailed to facilitate the Board’s adjudication of the claim. See Monzingo, Stefl, Ardison, and Green, all supra. Although Mr. Cartagena-Vazquez believesthat the May2012 VA hypertension examination violates the principle that “[s]ervice connection may be granted for any disease diagnosed after 13
discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service,” 38 C.F.R. § 3.303(d) (2013), he has not identified any evidence of record, nor can the Court locate any, that indicates that he had high blood pressure or some other indicator of hypertension in service or exposure that as likely as not initiated the later development of hypertension. Therefore, he has failed to carry his burden of demonstrating error in that regard. See Hilkert v. West, 12 Vet.App. 145, 151 (1999) (en banc) (holding that the appellant has the burden of demonstrating error). Absent any further assertion of error, the Court concludes that the Board did not clearly err in finding the May 2012 VA hypertension examination to be adequate. See D’Aries v. Peake, 22 Vet.App. 97, 104 (2008) (Court reviews the Board’s determination that a medical examination or opinion is adequate under the “clearly erroneous” standard of review). However, given that the duty to assist has not yet been satisfied and VA’s actions may result in additional medical records being associated with the claims file, the Board must reevaluate the adequacy of that examination after the required development is complete and consider whether a new medical examination is warranted in light of that development. If the Board determines that a new medical examination is not necessary and that the May 2012 VA hypertension examination remains adequate, it must provide adequate reasons or bases for those determinations. See Duenas v. Principi, 18 Vet.App. 512, 517 (2004). III. CONCLUSION Upon consideration of the foregoing, the appealed portions of the March 7, 2013, Board decision are SET ASIDE and the matters are REMANDED for further development, if necessary, and readjudication consistent with this decision. DATED: April 23, 2014 Copies to: Kathy A. Lieberman, Esq. VA General Counsel (027) 14 Advertisements
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