Citation Nr: 0808582 Decision Date: 03/14/08 Archive Date: 03/20/08 DOCKET NO. 03-12 176A ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for tinnitus. 2. Entitlement to service connection for anemia. 3. Entitlement to service connection for a split in the abdomen. 4. Entitlement to service connection for sickle cell trait. 5. Entitlement to service connection for arthritis of the arms, shoulder, ankles, and neck. 6. Entitlement to service connection for a right shoulder disability. 7. Entitlement to service connection for post-traumatic stress disorder (PTSD). 8. Entitlement to service connection for asbestosis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD J. Connolly Jevtich, Counsel INTRODUCTION The veteran served on active duty from October 1978 to October 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. The claim has been transferred to the San Juan, the Commonwealth of Puerto Rico RO. In December 2007, the veteran testified before the undersigned in Washington, D.C., at a Board hearing. Issues #4-8 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. FINDINGS OF FACT 1. Tinnitus is not attributable to service. 2. The veteran does not have anemia. 3. The veteran does not have a split in the abdomen. CONCLUSIONS OF LAW 1. Tinnitus was not incurred or aggravated in active service. 38 U.S.C.A. §§ 1101, 1131 (West 2002 & Supp. 2006); 38 C.F.R. §§ 3.303, 3.304 (2007). 2. Anemia was not incurred or aggravated in active service. 38 U.S.C.A. §§ 1101, 1131 (West 2002 & Supp. 2006); 38 C.F.R. §§ 3.303, 3.304 (2007). 3. A split in the abdomen was not incurred or aggravated in active service. 38 U.S.C.A. §§ 1101, 1131 (West 2002 & Supp. 2006); 38 C.F.R. §§ 3.303, 3.304 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) With respect to the claimant's claim, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Prior to the initial adjudication of the claimant's claims, a letter dated in November 2004 fully satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The claimant was aware that it was ultimately the claimant's responsibility to give VA any evidence pertaining to the claim. The VCAA letter told the claimant to provide any relevant evidence in the claimant's possession. See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). ). In particular, the VCAA notification: (1) informed the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) informed the claimant about the information and evidence that VA will seek to provide; (3) informed the claimant about the information and evidence that the claimant is expected to provide; and (4) requested that the claimant provide any evidence in his possession that pertains to the claims, or something to the effect that the claimant should "give us everything you've got pertaining to your claim." See Pelegrini II. The United States Court of Appeals for the Federal Circuit (Federal Circuit) recently held that a statement of the case (SOC) or supplemental statement of the case (SSOC) can constitute a "readjudication decision" that complies with all applicable due process and notification requirements if adequate VCAA notice is provided prior to the SOC or SSOC. See Mayfield v. Nicholson, No. 2007-7130 (Fed. Cir. Sept 17, 2007) (Mayfield III). As a matter of law, the provision of adequate VCAA notice prior to a readjudication "cures" any timing problem associated with inadequate notice or the lack of notice prior to an initial adjudication. See Mayfield III, (citing Mayfield v. Nicholson, 444 F.3d at 1328, 1333- 34). In any event, the Board finds that any deficiency in the notice to the claimant or the timing of these notices is harmless error. See Overton v. Nicholson, 20 Vet. App. 427, 435 (2006) (finding that the Board erred by relying on various post-decisional documents to conclude that adequate 38 U.S.C.A. § 5103(a) notice had been provided to the claimant, the Court found that the evidence established that the claimant was afforded a meaningful opportunity to participate in the adjudication of the claim, and found that the error was harmless, as the Board has done in this case.) If any notice deficiency is present, the Board finds that the presumption of prejudice on VA's part has been rebutted in this case by the following: (1) based on the communications sent to the veteran over the course of this appeal, the claimant clearly has actual knowledge of the evidence he is required to submit in this case; and (2) based on the claimant's contentions as well as the communications provided to the claimant by VA, it is reasonable to expect that the claimant understands what was needed to prevail. See also Simmons v. Nicholson, 487 F. 3d 892 (2007); see also Sanders v. Nicholson, 487 F. 3d 881 (2007). VA also fulfilled its duty to obtain all relevant evidence with respect to the issue on appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The claimant's service medical records, VA medical treatment records, Social Security Administration (SSA) records, and identified private medical records have been obtained, to the extent available. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. There is no indication in the record that any additional evidence, relevant to the issue decided herein, is available and not part of the claims file. The claimant was also afforded a VA examination in February 2001. 38 C.F.R. § 3.159(c)(4). The records satisfy 38 C.F.R. § 3.326. The Board notes that during the veteran's hearing, she made allegations regarding the adequacy of the VA examinations due to an apparent lack of access to the claims file. The Board has determined, taking into account this allegation as well as other considerations, that issues #4-8 must be remanded for additional development including a new VA examination. However, the appeal as to the issues of service connection for service connection for tinnitus, anemia, and a split in the abdomen, may proceed on the merits. The standards of the Court's recent decision in McLendon v. Nicholson, 20 Vet. App. 79 (2006), have not been met. Under McLendon, VA must provide a medical examination in a service connection claim when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. Id at 81. Even if the claims file was not reviewed by the VA examiner, the record (as discussed below) shows that tinnitus is due to a tumor which has not been service-connected and the veteran does not have anemia or a split in the abdomen. Since the veteran does have diagnoses of the other claimed disabilities, the Board is remanding those issues for clarification regarding their etiologies. Since the Board has concluded that the preponderance of the evidence is against the claim of service connection, any questions as to the appropriate disability rating or effective date to be assigned are rendered moot, and no further notice is needed. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. §§ 3.303, 3.304. Further, VA regulation provides that, with chronic disease shown as such in service (or within an applicable presumptive period under section 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of an evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). In addition, service connection may be granted for any disease diagnosed after 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). A claim for service connection generally requires competent evidence of a current disability; proof as to incurrence or aggravation of a disease or injury in service, as provided by either lay or medical evidence, as the situation dictates; and competent evidence as to a nexus between the inservice injury or disease and the current disability. Cohen v. Brown, 10 Vet. App. 128, 137 (1997); Layno v. Brown, 6 Vet. App. 465 (1994). The Court of Appeals for Veterans Claims (Court) has consistently held that, under the law cited above, "[a] determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service." Watson v. Brown, 4 Vet. App. 309, 314 (1993). This principle has been repeatedly reaffirmed by the U.S. Court of Appeals for the Federal Circuit (Federal Circuit), which has stated, "a veteran seeking disability benefits must establish . . . the existence of a disability [and] a connection between the veteran's service and the disability." Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To do so, the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). The veteran contends that she has tinnitus, anemia, and a split in her abdomen which are etiologically related to service. The veteran can attest to factual matters of which she had first-hand knowledge, e.g., experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). In addition, the veteran is a non-practicing nurse so she has some level of medical expertise. Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). In Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007), the Federal Circuit determined that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition (noting that sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. The relevance of lay evidence is not limited to the third situation, but extends to the first two as well. Whether lay evidence is competent and sufficient in a particular case is a fact issue. Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). See Barr v. Nicholson, 21 Vet App 303 (2007). As noted, the veteran is competent to report her medical complaints that she has observed and those to which she had medical expertise. The Board is mindful of the veteran that the veteran has suffered from a brain tumor and, by her own admission, has residual memory deficit. A review of the service medical records reveals no complaints, finding, treatment or diagnosis of tinnitus, anemia, or a split in the abdomen. Although the veteran delivered her children via Cesarean section, there is no evidence of residual abdominal "split" disability. The veteran's separation examination was negative for any of the claimed disabilities. It is significant to note that the veteran complained of medical problems during service and was treated for medical issues during service. However, she did not complain of tinnitus, anemia, or a split in her abdomen. The silence and the normal findings constitute negative evidence. See Forshey v. West, 12 Vet. App. 71, 74 (1998), aff'd sub nom. Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (noting that the definition of evidence encompasses "negative evidence" which tends to disprove the existence of an alleged fact). Thus, the absence of evidence constitutes negative evidence tending to disprove the claim that the veteran suffered from tinnitus, anemia, or a split in her abdomen in service which resulted in chronic disability or persistent symptoms thereafter. The veteran was discharged from service in October 1988. She filed a claim for VA benefits in 2000, over a decade later. A veteran's delay in asserting a claim can constitute negative evidence that weighs against the claim. Shaw v. Principi, 3 Vet. App. 365 (1992). The post-service record shows that in March 1996, the veteran began having headaches. The veteran also began having tinnitus in September 1996, particularly on the right side. An October 1996 magnetic resonance imaging (MRI) revealed a mass in the area of the clivus. A computerized tomography (CT) revealed a probable tumor. The veteran underwent a removal of a clival tumor in December 1996. However, even after the surgery, she continued to have persistent tinnitus. In June 1997, the veteran underwent a MRI of the brain which revealed a stable appearance in the region of the clivus and the para-nasal sinuses. In an October 2000 private medical report of R.R.A., M.D., it was indicated that the veteran continued to experience tinnitus as well as other symptoms following the clivus tumor. With regard to anemia, in 1994, the veteran was noted to have anemia and a fibroid uterus as well as a possible ovarian cyst. She underwent a dilation and cutterage (D and C) and diagnostic laparoscopy and peritoneal washing and lysis of adhesions. In 1996, the veteran experienced continuous vaginal bleeding for 3 weeks. She also had a fibroid uterus and adenomatous hyperplasia of endometrium. She underwent a D and C in August 1996. In October 1997, the veteran was admitted to hospitalization for menometrorrhagia and anemia to undergo a total abdominal hysterectomy which was performed. In an October 2000 private medical report of R.R.A., M.D., it was indicated that the veteran's anemia resolved after she underwent the hysterectomy. In February 2001, the veteran was afforded a VA examination. Her abdomen was examined. She was normal to inspection and had bowel sounds in all there quadrants. On palpation, there was no hepatosplenectomegaly or other masses. The abdomen was non-tender and non-distended. The veteran was not diagnosed as having any gastrointestinal or abdominal split nor was any such disability shown on examination. The examiner also noted that the record showed increasing tinnitus in her record, but not on the current examination. There was no anemia shown on examination. In sum, tinnitus was diagnosed approximately 8 years after service, was related to a clivus tumor, and has unfortunately remained even after the tumor was excised. The veteran is not service-connected for the clivus tumor. The service medical records are negative for any complaints, findings, treatment, or diagnosis of tinnitus. Although the veteran is a nurse, her opinion that tinnitus is due to service is outweighed by the other competent medical evidence which clearly shows that there were no inservice findings of tinnitus and that the onset of the tinnitus was in conjunction with the clivus tumor in 1996. That medical evidence is more probative than the veteran's opinion. Therefore, the preponderance of the evidence is against this claim of service connection. With regard to anemia, the veteran had anemia in conjunction with gynecological problems beginning around 1994. Although the veteran is a nurse, her opinion that she has anemia due to service is outweighed by the other competent medical evidence which clearly shows that the anemia was present post-service and resolved with her hysterectomy. That medical evidence is more probative than the veteran's opinion. In McClain v. Nicholson, 21 Vet App 319 (2007), the Court held that the requirement that a current disability be present 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 . . . even though the disability resolves prior to the Secretary's adjudication of the claim" (emphasis added). Under such circumstances, provided the resolved disability is related to service, a claimant would be entitled to consideration of staged ratings. However, a nexus to service is still required. In this case, anemia was not present during the pendency of the claim and the more probative evidence of record establishes that it was not related to service. With regard to an abdominal split, the veteran has delivered children via Cesarean section. However, no residual abdominal/gastrointestinal disability was identified on separation. Further, the post-service VA examination shows that there is no current abdominal/gastrointestinal disability. The Court has consistently held that, under the law cited above, "[a] determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service." Watson v. Brown, 4 Vet. App. 309, 314 (1993). This principle has been repeatedly reaffirmed by the Federal Circuit, which has stated, "a veteran seeking disability benefits must establish . . . the existence of a disability [and] a connection between the veteran's service and the disability." Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that the VA's and the Court's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In the absence of proof of a present disability, there can be no valid claim. Rabideau v. Derwinski, 2 Vet. App. 141, 143- 44 (1992). In this case, the veteran does not have anemia or a gastrointestinal split. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The preponderance is against the veteran's claim, and it must be denied. ORDER Service connection for tinnitus is denied. Service connection for anemia is denied. Service connection for a split in abdomen is denied. REMAND Sickle Cell Trait Sickle cell trait alone, without a history of directly attributable pathological findings, is not a ratable disability. Under Diagnostic Code 7714, asymptomatic sickle cell anemia, established case in remission, but with identifiable organ impairment warrants a 10 percent evaluation. The associated Note states that sickle cell trait alone, without a history of directly attributable pathological findings, is not a ratable disability. Cases of symptomatic sickle cell trait are to be forwarded to the Director, Compensation and Pension Service, for consideration under 38 C.F.R. § 3.321(b)(1). See 38 C.F.R. § 4.117, Diagnostic Code 7714. In this case, the service medical records show that the veteran was noted to have sickle cell trait during service in October 1979. Post-service, a June 1997 medical record questioned whether the veteran had ever been noted to have sickle cell trait. It is unclear if the veteran has any symptomatic sickle cell trait and directly attributable pathological findings. Accordingly, the veteran should be afforded a VA examination to make this assessment. Arthritis of the Arms, Shoulder, Ankles, and Neck The veteran has been diagnosed as having polyarthritis. As noted, the veteran's representative made allegations that the February 2001 VA examination did not include a review of the claims file in order to render an etiological opinion. As such, the veteran should be afforded a VA examination to determine if current diagnosis of polyarthritis is related to service or is arthritis was manifest within one year of service discharge. Right Shoulder Disability Post-service medical records show that the veteran has non- specific densities of the proximal right humerus and the veteran complains of right shoulder pain. As noted, the veteran's representative made allegations that the February 2001 VA examination did not include a review of the claims file in order to render an etiological opinion. As such, the veteran should be afforded a VA examination to determine if any right shoulder disability is related to service. PTSD The February 2001 VA examination diagnosed the veteran as having a depressive disorder and PTSD, but there was no chart available for review. Thereafter, medical evidence shows that the veteran might not have PTSD. The veteran should be afforded a new examination which includes a review of the claims file. The examiner should resolve whether or not the veteran has PTSD. In the event that the veteran has PTSD or any other psychiatric impairment, the examiner should provide the etiological basis for that diagnosis. Asbestosis As to claims of service connection for asbestosis or other asbestos-related diseases, VA has issued a circular on asbestos-related diseases. This circular, DVB Circular 21- 88-8, Asbestos-Related Diseases (May 11, 1988) (DVB Circular), provides guidelines for considering compensation claims based on exposure to asbestos. The information and instructions from the DVB Circular were included in a VA Adjudication Procedure Manual, M21-1 (M21- 1), Part VI, para. 7.68 (Sept. 21, 1992). Subsequently, the M2-1 provisions regarding asbestos exposure were amended. The new M21-1 guidelines were set forth at M21-1, Part VI, para. 7.21 (Oct. 3, 1997). The guidelines provide, in part, that the clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal disease; that VA is to develop any evidence of asbestos exposure before, during and after service; and that a determination must be made as to whether there is a relationship between asbestos exposure and the claimed disease, keeping in mind the latency period and exposure information. See Ashford v. Brown, 10 Vet. App. 120 (1997); McGinty v. Brown, 4 Vet. App. 428 (1993). The applicable section of Manual M21-1 also notes that some of the major occupations involving exposure to asbestos include mining, milling, work in shipyards, carpentry and construction, manufacture and servicing of friction products such as clutch facings and brake linings, manufacture and installation of roofing and flooring materials, asbestos cement and pipe products, military equipment, etc. High exposure to respirable asbestos and a high prevalence of disease have been noted in insulation and shipyard workers, and this is significant considering that, during World War II, U.S. Navy veterans were exposed to chrysotile, amosite, and crocidolite that were used extensively in military ship construction. Furthermore, it was revealed that many of these shipyard workers had only recently come to medical attention because the latent period for asbestos-related diseases varies from 10 to 45 or more years between first exposure and development of disease. Also of significance is that the exposure to asbestos may be brief (as little as a month or two) or indirect (bystander disease). See Department of Veterans Affairs, Veteran's Benefits Administration, Manual M21-1, Part 6, Chapter 7, Subchapter IV, § 7.21 b. In Dyment v. West, 13 Vet. App. 141, 145 (1999), the Court found that provisions in former paragraph 7.68 (predecessor to paragraph 7.21) of VBA Manual M21-1, Part VI, did not create a presumption of exposure to asbestos. Medical nexus evidence is required in claims for asbestos related disease related to alleged asbestos exposure in service. VAOPGCPREC 4-00. In short, with respect to claims involving asbestos exposure, VA must determine whether or not military records demonstrate evidence of asbestos exposure during service, develop whether or not there was pre-service and/or post-service occupational or other asbestos exposure, and determine whether there is a relationship between asbestos exposure and the claimed disease. See M21-1, Part VI, 7.21; DVB Circular 21- 88-8, Asbestos-Related Diseases (May 11, 1988). Thus, VA must analyze the veteran's claim of entitlement to service connection for asbestosis under these administrative protocols using the following criteria. Ennis v. Brown, 4 Vet. App. 523, 527 (1993). As noted, the latency period for asbestos-related diseases varies from 10 to 45 or more years between first exposure and development of disease. M21-1, Part VI, 7.21(b)(2), p. 7-IV- 3 (January 31, 1997). An asbestos-related disease can develop from brief exposure to asbestos. Id. M21-1, Part VI, para. 7.21 contains guidelines for the development of asbestos exposure cases. Part (a) in essence acknowledges that inhalation of asbestos fibers can result in fibrosis and tumors, and produce pleural effusions and fibrosis, pleural plaques, mesotheliomas of the pleura and peritoneum, and cancer of the lung, gastrointestinal tract, larynx, pharynx and urogenital system (except the prostate), with the most common resulting disease being interstitial pulmonary fibrosis (asbestosis). Also noted is the increased risk of bronchial cancer in individuals who smoke cigarettes and have had prior asbestos exposure. M21-1, Part VI, para. 7.21(b) pertains to occupational exposure, and acknowledges that high exposure to asbestos and a high prevalence of disease have been noted in insulation and shipyard workers. Noted is that the latent period varies from 10-to-45 or more years between first exposure and development of disease. Also of significance is that the exposure to asbestos may be brief (as little as a month or two) or indirect (bystander disease). M21-1, Part VI, para. 7.21(c) provides that the clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal lung disease. M21-1, Part VI, para. 7.21(d) provides that VA must determine whether military records demonstrate evidence of asbestos exposure in service; whether there is pre-service and/or post-service evidence of occupational or other asbestos exposure; and then make a determination as to the relationship between asbestos exposure and the claimed diseases, keeping in mind the latency and exposure information pertinent to the veteran. In this case, the record shows that the RO has not complied with M21-1 procedures. The veteran has not been sent the appropriate letter regarding alleged asbestos exposure. In the event that it is determined that the veteran has a documented history of probable asbestos exposure during service, the veteran should be afforded a VA examination. The examiner should opine if the veteran currently has a respiratory disability which is attributable to service to include probable asbestos exposure during service. Accordingly, this matter is REMANDED for the following actions: 1. Send the veteran a letter in compliance with DVB Circular and M21-1, Part VI regarding alleged asbestos exposure. 2. Schedule the veteran for a VA examination. The claims file must be made available to the examiner and the examiner should indicate in his/her report whether or not the claims file was reviewed. Any indicated tests, including X-rays if indicated, should be accomplished. A rationale for any opinion expressed should be provided. With regard to sickle cell trait, the examiner should determine if the veteran has any symptomatic sickle cell trait and directly attributable pathological findings. With regard to polyarthritis, the examiner should opine as to whether it is more likely than not, less likely than not, or at least as likely as not, that arthritis is related to service or was manifest within one year or service discharge. With regard to a right shoulder disability, the examiner should determine if the veteran has a current disability and, if so, the examiner should opine as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current disability is related to service. With regard to PTSD, the examiner should resolve the exact nature and diagnosis of any current psychiatric disability. Based on examination findings, historical records, and medical principles, the physician should give a medical opinion, with full rationale, as to whether the veteran currently has PTSD under DSM IV. The examiner should specifically identify the verified stressor(s) which is(are) responsible for PTSD, if diagnosed. Additionally, if the examiner notes the presence of any coexistent psychiatric disability, an opinion should be provided as to whether such psychiatric disability is more likely than not, less likely than not, or at least as likely as not related to service. With regard to asbestosis, the examiner should opine whether it is more likely than not, less likely than not, or at least as likely as not, that the veteran currently has a chronic respiratory disability that is attributable to service to include probable asbestos exposure during service. 3. The AMC should then readjudicate the claims on appeal in light of all of the evidence of record and taking into consideration M21-1, Part VI with regard to the asbestosis claim. If any issue remains denied, the veteran should be provided with a supplemental statement of the case as to any issue remaining on appeal, and afforded a reasonable period of time within which to respond thereto. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). 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 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). ______________________________________________ John Kitlas Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs