BVA9506181 DOCKET NO. 91-51 950 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for hypoglycemia. 2. Entitlement to an evaluation in excess of 10 percent for status post surgery, right acromioclavicular joint. REPRESENTATION Appellant represented by: AMVETS WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD G. Wm. Thompson, Counsel INTRODUCTION The veteran retired from active military service in March 1990, after completing more that 20 years of active duty. This case was previously before the Board of Veterans' Appeals (Board) in October 1992, and in that decision service-connection was granted for post-operative residuals of right shoulder disability; the issue of entitlement to service connection for actinic keratoses was remanded for further development. By rating action in March 1993, per the October 1992 Board determination, service-connection was established for status-post surgery of the right acromioclavicular joint, and a 10 percent rating was assigned. The veteran has not expressed disagreement with that rating action as pertains to the skin disorder. In that same determination, service connection was denied for actinic keratoses, tinnitus, and hypoglycemia. A Supplemental Statement of the Case issued in June 1993 referred to issues previously dismissed by the veteran. In hearing testimony in September 1993, the issues were clarified and determined to be entitlement to service connection for hypoglycemia and a skin disorder variously diagnosed as tinea versicolor, actinic keratoses and contact dermatitis, and entitlement to an increased rating for right shoulder disability. The issue of an increased rating for right ear hearing loss was withdrawn. The Hearing Officer, in November 1993, granted service-connection for contact dermatitis, and continued the denial of service connection for hypoglycemia, and entitlement to an increased rating for right shoulder disability. By rating action in September 1994, per the Hearing Officer's determination in November 1993, service-connection was established for contact dermatitis, and a zero percent rating was assigned. The veteran has not expressed disagreement with that rating action as pertains to the skin disorder. In that same rating action the veteran was denied service connection for hypoglycemia, and entitlement to an increased rating for right shoulder disability. The veteran's representative, in a written presentation dated in February 1995, raised the issues of entitlement to service connection for tinnitus and a right elbow disability and an increased rating for low back disability. The Board notes that service connection was denied for right elbow disability by rating action in June 1991, and that this issue was withdrawn in November 1991. Service connection was denied for tinnitus by rating action in March 1993, and there was no notice of disagreement filed in regard to that issue within one year of notification of the denial. New and material evidence would be required to reopen the issues of entitlement to service connection for tinnitus and right elbow disability. In regard to the issue of entitlement to an increased rating for low back disability, that issue is not inextricably intertwined with the issues on appeal, has not been developed for appeal and will not be considered by the Board at this time. The RO's attention is directed to the representative's February 1995 statement for action deemed appropriate. REMAND In 1982, during service, the veteran was reported to have hypoglycemia that was variously described as being either reactive, symptomatic, asymptomatic, controlled by diet or by history. There was no diagnosis of any underlying disease or disability, and the service records do not show any active response to any hypoglycemia after 1982. In hearing testimony in September 1993, the veteran reported that, while he had not seen a doctor for hypoglycemia since service, that he currently had symptoms every day. He stated that a special high protein low carbohydrate diet was required, to include eating 6 to 7 meals a day. Transcript (Tr.) at 4-5. The RO denied service connection for hypoglycemia on the basis that there was no current diagnosis of hypoglycemia or associated disease. The Board notes that the veteran has not been examined specifically for hypoglycemia or any underlying disease process, and the evidence is inadequate to decide the issue of service connection. The medical evidence of record clearly shows that the veteran's right clavicle was surgically shortened, and that there is obvious separation between the end of the right clavicle and the acromion. The right shoulder disability is rated under Diagnostic Code 5203, which offers a 20 percent evaluation when there is nonunion of the clavicle, with loose movement. In hearing testimony, in September 1993, the veteran reported that when he lifted objects the "collarbone separated" and would "stay up for a day or two" and then it would eventually "settle down." Tr. at 4. There is no recorded medical opinion as to whether the separation between the end of the clavicle and the acromion is the equivalent of nonunion and whether the event described by the veteran would constitute loose movement. This case is remanded for action as follows: 1. The veteran should be permitted to submit or identify any other evidence in support of his claim. Medical evidence or opinion relating to hypoglycemia in service and since service, and medical evidence regarding his right shoulder disorder would be helpful. Evidence identified should be obtained by the RO. If he has been treated for hypoglycemia or his right shoulder disability by VA, the military, or private medical care providers since service, he should identify them and the RO should obtain copies of his records. 2. The RO should provide the veteran an examination by an internal medicine specialist, in order to determine whether he has hypoglycemia and/or any underlying disease process. All appropriate laboratory studies and other diagnostic tests are to be performed. The examination is to be conducted in accordance with the VA's Physician's Guide for Disability Evaluation Examinations. Following examination, the examiner should provide an opinion as to whether hypoglycemia is present; what its etiology is, if present; and whether any current hypoglycemia is related to the hypoglycemia in service. The claims folder and a separate copy of this remand must be made available to the examiner. 3. The veteran should also be accorded an examination by a VA orthopedic specialist, in accordance with the Physician's Guide for Disability Evaluation Examinations, in order to determine the nature, extent and status of the service-connected right shoulder disability. The examiner is to evaluate the veteran's complaints of movement of the clavicle, and provide an opinion as to whether there is nonunion of the clavicle, with loose movement. All necessary special studies and tests are to be accomplished. The claims folder and a separate copy of this remand must be made available to the examiner. Following completion of the foregoing, the RO must review the record and ensure that all of the requested development has been conducted and completed in full. If any development is incomplete, including if the requested examinations do not include all test reports, special studies or opinions requested, appropriate corrective action is to be implemented. Thereafter, the case should be readjudicated. If any benefit sought remains denied, the veteran and his representative should be provided with a supplement statement of the case and be given opportunity to respond. The case should then be returned to the Board for further appellate consideration. The veteran need take no action until notified. JANE E. SHARP Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. 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) (1994).