Citation Nr: 0500244 Decision Date: 01/05/05 Archive Date: 01/19/05 DOCKET NO. 95-16 988 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a blood disorder, as secondary to the service-connected disability of porphyria cutanea tarda (PCT). 2. Entitlement to service connection for liver damage, including Hepatitis C, as secondary to the service connected disability of PCT. 3. Entitlement to service connection for post-traumatic stress disorder (PTSD). 4. Entitlement to an increased evaluation for PCT, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and Appellant's Spouse ATTORNEY FOR THE BOARD L.J. Bakke, Counsel INTRODUCTION The veteran served on active duty from January 1969 to April 1972. This appeal arises before the Board of Veterans' Appeals (Board) from rating decisions rendered in January 1996, May 2001, and October 2002 by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In June 1997, the Board remanded the veteran's claim seeking entitlement to service connection for PCT. Also in the introduction to this decision the Board referred for the RO's action the veteran's January 1997 notice of disagreement to its January 1996 rating decision denying a claim for service connection for PTSD-of which notice was given in February 1996. In an April 2001 decision, the Board granted the claim for service connection for PCT, as a residual of exposure to the herbicide Agent Orange, and remanded for further development the claim of service connection for PTSD. In a May 2001 rating decision, the RO effectuated the grant of service connection for PCT, assigning a 10 percent evaluation. The veteran submitted a timely notice of disagreement as to the evaluation assigned this condition. In an October 2002 rating decision, the RO confirmed and continued the 10 percent evaluation assigned and, in addition, denied entitlement to service connection for a blood disorder and liver damage, including Hepatitis C, as secondary to the service connected PCT. The veteran submitted a timely notice of disagreement with this decision and, upon issuance of a statement of the case in December 2003, submitted a timely substantive appeal as to all issues in January 2004. The case has been returned to the Board for further appellate consideration. The U.S. Court of Appeals for Veterans Claims (Court) has held that unlike in claims for increased ratings, "staged ratings" or separate ratings for separate periods of time may be assigned based on the facts found following the initial grant of service connection. Fenderson v. West, 12 Vet. App. 119 (1999). In this case, the RO granted entitlement to service connection for PCT in the May 2001 rating decision, granting a 10 percent evaluation. The veteran appealed the rating assigned. Hence, the Board will consider the proper evaluation to be assigned for the veteran's service connected PCT from the time period beginning with the grant of original service connection, pursuant to the Court's holding in Fenderson, supra. The veteran testified in August 2004 before the undersigned Veterans Law Judge, who was designated by the Chairman to conduct the hearings pursuant to 38 U.S.C.A. § 7102(b) (West 2002) and who will participate in this decision. A copy of the hearing transcript issued following the hearing is of record. The issues of entitlement to service connection for liver disease, to include Hepatitis C, and to an increased evaluation for PCT, currently evaluated as 10 percent disabling are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the veteran if further action is required on his part. FINDINGS OF FACT 1. At a August 2004 hearing before the undersigned Veterans Law Judge, and prior to the promulgation of a decision in the appeal, the veteran withdrew his appeal concerning the issue of entitlement to service connection for a blood disorder, as secondary to his service-connected PCT. 2. The VA has properly developed and obtained all relevant evidence needed for an equitable disposition of, and adequately notified the veteran of the evidence necessary to substantiate the claim of service connection for PTSD addressed in this decision. 3. The evidence of record reflects that the veteran engaged in combat during his service in Vietnam. 4. The medical evidence shows that the veteran has been diagnosed with PTSD which is medically attributed to stressors he experienced during his service in Vietnam. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a Substantive Appeal by the appellant have been met concerning the issue of entitlement to service connection for a blood disorder, as secondary to his service-connected PCT. 38 U.S.C.A. § 7105(b)(2) (West 2002); 38 C.F.R. §§ 20.202, 20.204(b),(c) (2004). 2. Service connection for PTSD is warranted. 38 U.S.C.A. §§ 1110, 1154, 5102, 5103 and 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2004). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Withdrawal The Secretary shall decide all questions of law and fact necessary to a decision by the Secretary under a law that affects the provision of benefits by the Secretary to the veterans or the dependents or survivors of veterans. 38 U.S.C.A. § 511(a) (West 2002). All questions in a matter which under section 511(a) of title 38, United States Code, are subject to decision by the Secretary shall be subject to one review on appeal to the Secretary. Final decisions on such appeals shall be made by the Board. Decisions of the Board shall be based on the entire record in proceedings and upon consideration of all evidence and material of record and applicable provisions of law and regulation. 38 U.S.C.A. § 7104(a) (West 2002). The Board may dismiss any appeal which fails to allege error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2002). In addition, a Substantive Appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. §§ 20.202, 20.204(b) (2004). Withdrawal may be made by the appellant or by his or her authorized representative, except that a representative may not withdraw a Substantive Appeal filed by the appellant personally without the express written consent of the appellant. 38 C.F.R. § 20.204(c) (2004). Concerning the issue of entitlement to service connection for a blood disorder, as secondary to his service connected PCT, bipolar disorder and depression, the veteran submitted a VA Form 9 in January 2004 perfecting his appeal as to this issue, as identified in the December 2003 statement of the case. In August 2004, he provided testimony before the undersigned Veterans Law Judge. At this time he clarified his wishes with regard to his appeal, stating specifically that he wished to withdraw the issue of service connection for a separate blood disorder as secondary to the service-connected PCT. In so stating, however, he noted that the medical definition of PCT is of a metabolic blood disorder which manifests itself in skin and other organ symptomatology. The transcript has been reduced to writing and is of record. See Tomlin v. Brown, 5 Vet. App. 355, 357-58 (1993) (holding that testimony at a hearing, once reduced to writing, can be construed as an NOD). As the appellant has withdrawn his appeal as to the issue of entitlement to service connection for a separate blood disorder, as secondary to his service-connected PCT, there remain no allegations of errors of fact or law for appellate consideration concerning this issue. The Board therefore has no jurisdiction to review the issue. Accordingly, this issue is dismissed. II. Service Connection for PTSD There was a significant change in the law during the pendency of this appeal. On November 9, 2000, the President signed into law the Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002). This law redefined the obligations of VA with respect to the duty to assist, and imposed on VA certain notification requirements. The final regulations implementing the VCAA were published on August 29, 2001, and they apply to most claims for benefits received by VA on or after November 9, 2000, as well as any claim not decided as of that date. 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). The Board is granting the veteran's claim seeking entitlement to service connection for PTSD. No additional evidence is required to make a determination as to this issue, and, hence, any failure to comply with VCAA requirements as to this issue would not be prejudicial to the veteran. 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Bernard v. Brown, 4 Vet. App. 384 (1993). Service connection may be established for disability resulting from personal injury or disease incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). Regulations also provide that service connection may be established where all the evidence of record, including that pertinent to service, demonstrates that the veteran's current disability was incurred in service. 38 C.F.R. § 3.303(d). Service connection for PTSD requires the following: 1) medical evidence of a diagnosis of PTSD in accordance with the criteria of Diagnostic and Statistical Manual of Mental Disorders (4th ed., 1994) (DSM-IV), which is presumed to include both adequacy of the PTSD symptomatology and sufficiency of a claimed inservice stressor; 2) credible supporting evidence that the claimed inservice stressor actually occurred; and 3) medical evidence of a link, or nexus, between the current symptomatology and the claimed inservice stressor. 38 C.F.R. § 3.304(f), 4.125 (2004); Cohen v. Brown, 10 Vet. App. 128, 138 (1997). For the purposes of establishing service connection, a stressor is a traumatic event 1) to which the veteran was exposed during active service and in which the veteran "experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others"; and 2) which produced in the veteran a response involving intense fear, helplessness, or horror. Cohen, at 141 (citing DSM- IV). In the present case, the medical evidence of record presents two diagnoses of PTSD. The first, proffered by the private treating physician, James V. Diodato, M.D., in April 1995 reflects that the veteran had been seen as early as 1974 and 1975 for treatment when, according to Dr. Diodato, he then presented with repeated re- experiencing of the traumatic events he experienced on active duty in Vietnam, including nightmares and daytime flashbacks; loss of interest in most activities of daily living and withdrawal from society in general; markedly constricted affect and dysphoric mood; alienation from others, especially his family; persistent symptoms of sleep disturbances, hypervigilance, and difficulties in focusing, concentrating, and planning. The physician diagnosed chronic PTSD causally related to the veteran's Vietnam experiences. The second diagnosis of PTSD is documented in a VA examination report dated in October 2003. In this report, the examiner notes specifically that the veteran's three- volume claims file and medical record have been reviewed. In addition, the examiner conducted a clinical interview and administered the Mississippi Scale and Minnesota Multiphasic Personality Inventory (MMPI-2)-both of which the examiner reported demonstrated scores consistent with diagnoses of PTSD. Following his analysis of the veteran's symptomatology and clinical data, the examiner diagnosed the veteran with PTSD, delayed onset. Concerning the etiology of his PTSD, the examiner offered the following opinion: The veteran is diagnosed with PTSD. He traces his symptoms to his enlistment. As a child he was easy going, friendly and socially active. Since the examination request states that no stressors from Vietnam are confirmed the examiner can not say that the PTSD is as likely as not from the traumatic event of seeing a driver killed in the truck that he had just left during a Vietnam operation. Based on the veteran's report it seems more likely that (sic) not that his PTSD can be related to Vietnam enlistment where he saw a driver he knew killed and saw many others maimed or dead. The Board therefore finds that the medical evidence establishes that the veteran manifests PTSD that is the result of stressful events he experienced during his active duty in Vietnam. The Board now turns to the question of verification of the veteran's averred stressors. The veteran avers that he suffers from PTSD as a result of stressors he experienced while on active duty as a heavy equipment operator assigned to an engineering company in Vietnam. Specifically, he testified that he, as part of his unit, operated heavy equipment required to build bridges and roads, minesweep roads, and clear landing zones. While performing these duties, he and others in his unit were routinely ambushed and came into contact with hostile action. Among the incidents that the veteran experienced, he personally witnessed the death of a driver who was driving a truck in which he had been a passenger. Some moments before the truck was struck by a rocket propelled grenade, and the driver killed, a lieutenant came up to the veteran and requested that he ride with the lieutenant in his jeep. The veteran complied, and hence his life was spared. He testified that he continues to have nightmares about this incident and other events he experienced in Vietnam. Service personnel records document that the veteran served in Vietnam from June 1970 to July 1971 as a light truck driver (military occupational specialty (MOS) 64A10) with HHC [redacted] Engineering Brigade. From July 1970 to May 1971, he served as a heavy vehicle driver (MOS 64B20) with the [redacted] Engineering Company (LE). The Board notes that the record does not reflect that the veteran was awarded the Combat Infantryman Badge, Purple Heart, or other decorations that would allow his participation in combat to be presumed. Therefore, the Board must analyze the evidence of record to determine whether or not the veteran served in combat. See 38 U.S.C.A. § 1154 (West 2002). See also Pentecost v. Principi, 16 Vet. App. 124 (2002); Collette v. Brown, 82 F.3d 389 (1996). An Internet search reveals that the [redacted] Engineering Company, the "[redacted]," was attached to the [redacted] Engineering Battalion (Combat) in Vietnam from July 1967 to August 1971. A history of the [redacted] Engineering Battalion shows that, from January 1970 to August 1971, the [redacted] Engineering Company (LE) was sub-attached to it. Primarily situated near Pleiku, the Battalion's mission ranged from Dak To in the north to Ban Me Thout in the south, and from the Cambodian operations in the west to An Khe in the east. The history notes that the Battalion's mission was highly fluid during this time, changing over from a primary mission of providing combat support to the 4th Infantry Division to a mission emphasizing lines of communication construction. In March 1970, a platoon from the [redacted] Engineer Company was assigned to work with a platoon from the [redacted] Engineer Company to prepare earthwork for QL-14S. As the year progressed, the Battalion became highly committed to Operation [redacted], described as a tremendous push to complete as many kilometers of pavement as possible. In February, the Battalion formed a provisional Dump Truck Company to provide the haul support for the extensive paving operations. All line companies provided trucks and a new unit with headquarters was formed to haul materials. During this time, the [redacted] Engineer Battalion continued to provide operational support, even as it provided full support to Operation [redacted]. The Battalion provided mine sweeps for 1/92 Artillery, airfield and revetment construction as well as repair for the [redacted] Aviation Battalion at Camp Holloway, rehabilitation of several fire support bases, and upgrade of outlying airfields. In late 1970, the Battalion took responsibility for projects of the [redacted] Engineering Battalion, shifting some of its efforts to vertical construction. The deactivation of the [redacted] Engineering Battalion left the [redacted] as the only major U.S. Engineer Unit in the entire Central Highlands. As the monsoon season ended, the [redacted] Engineer Battalion resumed the focus on line of communication maintenance, and construction of the QL-14S. Work was delayed due to a destructive fire at the asphalt plant. In mid November, the [redacted] Engineer Company moved from Qui Nhon into Camp Wilson with the mission of correcting earthwork and drainage on Route QL-14N. The Company completed this project in late March 1971, after which it moved south to assist in the earthwork requirements and construction of QL-14S. The project was completed in August 1971. Of pertinent importance is the following description of the conditions under which the [redacted] Engineering Battalion, and the [redacted] Engineering Company, as a support unit, performed this work: As the paving train and earthwork operations progressed southward in February and March (1971) enemy activity increased greatly. Mine incidents became an everyday occurrence, ambushes and sniper fire caused many delays, yet paving continued. Finally on 16 March a major NVA offensive was launched in the area and primarily directed against the city of Phu Nhon, which lay astride 14S roadway between Weight-Davis and LZ Lonely. The 95th NVA Regiment (Reinforced) established control over the 5 to 6 kilometers of 14S north of Phu Nhon and consequently cut off supplies to LZ Lonely. An immediate airlift of supplies to LZ Lonely enabled the units to prepare themselves defensively. The siege of Phu Nohn was finally lifted by the NVA on 22 March 1971 and vehicles were again able to travel to LZ Lonely. However, on 1 April 1971 the road was once again severed by NVA units. Landing Zone Lonely was described as having received mortar and rocket attacks daily during this time period; however, although five engineers were wounded at the LZ, none were killed in action at the LZ. The Board finds that these documents clearly establish the presence of the [redacted]Engineering Company in Vietnam from July 1967 to August 1971, and its assignment to the [redacted] Engineering Battalion from January 1970 to August 1971. These documents further clearly establish that the [redacted] Engineering Company, the "[redacted]," worked and served in an environment marked by hostile action and combat against the enemy. Therefore, the Board finds that the [redacted] Engineering Company, the "[redacted]," participated in combat against the enemy within the meaning of 38 U.S.C.A. § 1154. As before mentioned, service personnel records reflect that the veteran was assigned to [redacted]Engineering Company as a heavy vehicle driver from July 1970 to May 1971, including the period of the intense hostile activity recounted above. Moreover, the veteran's testimony and statements of events he experienced, including his sworn testimony before the undersigned Veterans Law Judge in August 2004 is consistent with these histories. The Board finds the veteran to be a credible witness. Hence, after consideration of all the evidence of record, the Board finds that the veteran served in combat. See 38 U.S.C.A. § 1154; see also Pentecost, supra; Suozzi v. Brown, 10 Vet. App. 307, 308-11 (1997); Collette, supra. The stressors identified by the veteran in his stressor statement and testimony, and as reported to the VA examiner in October 2003 are related to combat, including being subject to hostile fire; frequently ambushed and witnessing people being killed, dying, and wounded; and part of a convoy that was ambushed and witnessing the death by RPG of the driver of the truck in which he had been a passenger. As the veteran's service in combat is established, and as his in-service stressors are combat-related, the veteran's lay testimony, by itself, is sufficient to establish the occurrence of the stressful events. 38 U.S.C.A. § 1154 (West 2002); see also Cohen, at 146. In summary, the record presents a valid diagnosis of PTSD related to stressful experiences the veteran reported he underwent as a combat soldier in Vietnam. The evidence of record demonstrates that the veteran participated in combat as a heavy vehicle driver assigned to [redacted] Engineer Company, which was during this time attached to the [redacted] Engineering Battalion (Combat) and sub-assigned to the [redacted]Engineering Battalion in Vietnam. The Board is aware that, when it relies upon evidence developed or obtained after the most recent statement of the case or supplemental statement of the case, the claimant must be provided adequate notice of our intention to use such evidence and given an opportunity to respond. See Hilkert v. West, 12 Vet. App. 145, 151 (1999), citing Thurber v. Brown, 5 Vet. App. 119, 122 (1993). Notwithstanding, the Board finds, in the present case, that such notice and opportunity for response are unnecessary, as the evidence developed provides a basis upon which to grant the claim. See Bernard, supra. Accordingly, after careful review of all the evidence of record, the Board finds that the veteran manifests PTSD that is the result of stressors he experienced while exposed to combat as a result of his active duty in Vietnam. The Board therefore concludes that service connection for PTSD is appropriate. ORDER The appeal concerning entitlement to service connection for a blood disorder as secondary to his service-connected PCT is dismissed. Service connection for PTSD is granted. REMAND The veteran further seeks entitlement to service connection for liver damage, to include Hepatitis C, as secondary to his service-connected PCT, and to a higher evaluation for his service-connected PCT. The Board has reviewed the record and finds that additional development is necessary before appellate action may be completed in this case. In this regard, the Board notes that the September 2002 VA examination for skin disease, upon which the RO relied to confirm and continue the 10 percent evaluation assigned the service-connected PCT, provides an inadequate basis for evaluating this disability. In addition, the September 2002 VA examination for liver is merely a repeat of the examination for skin disease. The examination reveals findings of abnormal liver function but simply notes that while such a result may be caused by PCT, the veteran also tested positive for Hepatitis C. The report indicates that referral to a hepatologist is indicated. The report of any such examination or further testing is not of record, and the September 2002 report offers no opinion as to the cause of the Hepatitis C. No other liver condition is diagnosed as a result of the abnormal liver function test, even though the examiner opined that such a result may be etiologically linked to the service-connected PCT. The Board observes that the RO has rated the veteran's disability due to service-connected PCT as analogous to eczema, under Diagnosed Code 7899-7806, evaluating only those symptoms manifested by a skin condition. Yet, medical evidence establishes that PCT is manifested by hepatomegaly as well as other symptoms. "Porphyria cutanea tarda symptomatica," as defined by Dorland's Illustrated Medical Dictionary (27th ed. 1988 p. 1338), is a "sporadic form of porphyria characterized by chronic skin lesions ranging from slight skin fragility to severe chronic scarring, by hepatomegaly, and by excessive urinary excretion of uroporhyrin and coproporphyrin; it is usually associated with chronic alcoholism." Moreover, the veteran's private treating physician, Daniel L. Spitz, M.D., has submitted several statements attesting to the variety of symptoms the veteran experiences. The most recent is dated in July 2004 and documents the following: [The veteran] has been confirmed to have the disorder porphyry cutaneous tarda, a metabolic blood disorder that has skin and other organ manifestations. The skin manifestations are only present when the disease is not properly controlled or managed. [The veteran's] disease has been well controlled with multiple phlebotomies through the years; therefore his peripheral skin manifestations have been minimal. However, porphyria cutaneous tarda or PCT, is not solely a disease of the skin, it can have manifestations in many other organs, especially the liver. Porphyria cutaneous tarda has been documented, in various publications, to cause liver disease or to worsen an already existing liver problem. There has been proven a direct relationship between increasing age and progressive distortion of the liver architecture with fibrosis with the mean age presenting at age 48, cirrhosis by the age of 57 and hepatocellular carcinoma by the age of 66 with porphyria cutaneous tarda. This was shown by Cortes et all, in Histopathology 1980, September, volume IV, page 471 to 485. In another study presented by Armas in the Rev Med Chil in 1994, January, volume 122, pages 72-74 revealed that the patients with porphyria cutaneous tarda have a higher incidence of hepatitis C virus infections as well as hepatoma. The question is now raised does the patient have a liver disease. The patient does present now with abnormal liver function studies with elevated hepatic enzymes. A recent liver biopsy confirmed that hepatic fibrosis and bridging consistent with early fibrosis and possible early cirrhoses was present. He was found to have splenomegaly on physical exam and ultrasound, which is a sign of liver disease. Gallstones were also noted, which is also manifestation of a porphyria cutanaeous tarda. Therefore, I do believe that the patient does present at this time with laboratory, radiological and physical evidence of liver disease. *** The patient does have some other symptoms that are also related to his PCT like that of profound fatigue. VA treatment records further document that the veteran requires phlebotomies for treatment of his PCT. As the veteran's representative noted in August 2004, Diagnostic Code 7704, under the schedular criteria for evaluating disease of hemic and lymphatic systems, 38 C.F.R. § 4.117, affords an evaluation of 40 percent for those conditions requiring phelobotomy as a treatment. As the veteran meets this criteria, the representative's argument would seem to have merit. In Esteban v. Brown, 6 Vet. App. 259, 262 (1994), the Court held that evaluations for distinct disabilities resulting from the same injury could be combined so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. In a July 1, 1997 precedent opinion, the General Counsel of the VA observed that 38 C.F.R. § 4.71a, Diagnostic Code 5257 provides for evaluation of instability of the knee without reference to limitation of motion and held that a claimant who had both arthritis and instability of the knee may be rated separately under 38 C.F.R.§ 4.71a, Diagnostic Codes 5003 and 5257. The opinion clarified that the provisions of 38 C.F.R. § 4.14 prohibit the "evaluation of the same disability under various diagnoses." VAOPGPREC 23-97 (July 1, 1997; revised July 24, 1997). Finally, the Board notes that the veteran's treating physician, Dr. Spitz, specifically observed that PCT has been documented to cause liver disease or to worsen an already existing liver problem. The Court has held that when aggravation of a veteran's non- service connected disability is proximately due to or the result of a service-connected disease or injury, it too shall be service connected. See Allen v. Brown, 7 Vet. App. 439, 446 (1995). The RO has not had an opportunity to evaluate whether the veteran's PCT may be more appropriately evaluated under another diagnostic code or whether or not separate, compensable evaluations for the veteran's service-connected PCT are warranted. The Board thus finds it would be helpful to proffer the veteran current examinations-including all appropriate clinical testing and review of the claims file- in order to determine the nature, extent, and etiology of the claimed liver damage, including Hepatitis C, as secondary to the service-connected PCT, and to determine the nature and extent of the service-connected PCT. See 38 C.F.R. § 3.159(c)(4) (2003). In addition, as noted above, the Board notes that the veteran appealed the evaluation assigned his service-connected PCT in the original grant of service connection. See Fenderson, supra. The Board observes that the rating criteria governing the evaluation of hemic and lymphatic systems, under which the veteran's representative argues that the condition is more properly evaluated, were revised, effective October 23, 1995. See 60 Fed. Reg. 49227 (1995). Should the RO determine that evaluation under this criteria is warranted, notice of the revised criteria must be provided the veteran, and an analysis of the veteran's symptomatology under both the old and new during the course of the entire appeal must be accomplished. See VAOPGCPREC 7-2003 (Nov. 19, 2003). The Board notes that the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) in Disabled Veterans of America v. Secretary of Veterans Affairs (DAV v. Sec'y of VA), 327 F.3d 1339 (Fed. Cir. 2003) invalidated the Board's ability to cure VCAA deficiencies. Therefore a remand is required in this appeal so that additional development may be undertaken in order to fulfill the Department's duty to assist the appellant with his claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2003). Accordingly, and to ensure full compliance with due process requirements, further appellate consideration will be deferred and the case is REMANDED to the RO for the following development: 1. The RO must inform the appellant: (1) of the notification and duty to assist provisions of the VCAA and its implementing regulations, (2) about the information and evidence not of record that is necessary to substantiate his claim for entitlement to service connection for liver damage, including Hepatitis C, as secondary to the service- connected PCT, and an increased evaluation for PCT; (3) about the information and evidence that VA will seek to provide; (4) about the information and evidence the appellant is expected to provide; and (5) request or tell him to provide any evidence in his possession that pertains to his claim. The claims file must include documentation that there has been compliance with the VA's duties to notify and assist a claimant as set forth in the VCAA as specifically affecting the remaining issues on appeal. 2. The RO should request that the veteran identify all VA and non VA health care providers who treated him for his claimed liver damage and service- connected PCT. The RO should procure duly executed authorization for the release of private medical records. Furthermore, the appellant should be specifically informed as to what portion of evidence he is required/expected to submit, and which portion of the evidence the VA would attempt to obtain in order to assist the appellant in substantiating his claims, per 38 U.S.C.A. §§ 5103(a), 5103A; Quartuccio v. Principi, 16 Vet. App. 183 (2002) and Charles v. Principi, 16 Vet. App. 370 (2002)). 3. The RO should then obtain the veteran's medical records from all identified health care providers that are not already of record. In particular, the RO should request any and all outpatient and inpatient treatment records, to include any and all clinical medical records, of treatment accorded him by Drs. Spitz of West Palm Beach, Florida and Dr. Schillinger of Boca Raton, Florida that are not already of record. In addition, the RO should request any and all outpatient and inpatient treatment records, to include any and all clinical medical records accorded him by the VA Medical Center (VAMC) in West Palm Beach, Florida, and any other VAMC the veteran may identify, that are not already of record. 4. When the above development has been completed, the RO should make arrangements to afford the veteran VA examinations, by appropriate specialists, to determine the nature, extent, and etiology of his claimed liver damage, to include Hepatitis C, and the nature and extent of disability caused by his service-connected PCT. All indicated tests and studies should be performed. The claims folder, including all newly obtained evidence, must be sent to the examiner(s) for review. The examiner(s) should address the following matters: ? Summarize the medical history, including the onset and course, of his claimed liver damage, to include Hepatitis C, and his service-connected PCT. ? Describe any current symptoms and manifestations attributed to his claimed liver damage, to include Hepatitis C, and his service- connected PCT. ? Complete any diagnostic and clinical tests required and provide diagnoses for any and all liver, skin, blood and any other pathology identified. ? Concerning the claim for service connection for liver damage, including Hepatitis C, the examiner is requested to provide the following opinions: 1. Is it as likely as not that any diagnosed liver pathology, including Hepatitis C, is the result of the veteran's service connected PCT or, that any diagnosed liver pathology, including Hepatitis C, has been aggravated by the service-connected PCT? 2. In the alternative, is it as likely as not that any diagnosed liver pathology, including Hepatitis C, is the result of his active service, including exposure to the herbicide Agent Orange. ? In arriving at this opinion, the examiner is specifically requested to address the opinions of Dr. Spitz present in the claims folders. 5. After receipt of any and all newly acquired evidence, the RO should again review the veteran's claim for service connection for liver damage, including Hepatitis C, as secondary to his service- connected PCT, and for an increased evaluation for his service-connected PCT, to include consideration of Esteban, supra; Allen, supra. If the decision remains in any way adverse to the veteran, he and his representative should be furnished with a supplemental statement of the case, and with a reasonable period of time within which to respond. The case should thereafter be returned to the Board for further review, as appropriate. The veteran need take no action until he is so informed. 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, supra. The veteran is reminded that it is his responsibility to appear for any and all scheduled examinations and that failure to do so could result in the denial of his claim. 38 C.F.R. § 3.655 (2004). The Board intimates no opinion as to the ultimate outcome of this case. This claim must be afforded expeditious treatment. 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 Act of 2003, Pub. L. No. 108-183, § 707(a), (b), 117 Stat. 2651 (2003) (to be codified at 38 U.S.C. §§ 5109B, 7112). ______________________________________________ A. BRYANT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs