Citation Nr: 0811474 Decision Date: 04/08/08 Archive Date: 04/23/08 DOCKET NO. 04-12 116 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to an increased rating for chronic muscular strain superimposed on degenerative instability with sciatica, currently rated as 40 percent disabling. 2. Entitlement to service connection for chest tumor with blood spots, to include as due to herbicides (chemical), biological or radiation exposure. 3. Entitlement to service connection for abdomen and left shoulder tumor, to include as due to herbicides (chemical), biological or radiation exposure. 4. Entitlement to service connection for neuralgia, to include as due to herbicides (chemical), biological or radiation exposure. 5. Entitlement to service connection for pancreas disability, to include as due to herbicides (chemical), biological or radiation exposure. 6. Entitlement to service connection for persistent cough, to include as due to herbicides (chemical), biological or radiation exposure. 7. Entitlement to service connection for severe joint pain, to include as due to herbicides (chemical), biological or radiation exposure. 8. Entitlement to service connection for peripheral neuropathy, to include as due to herbicides (chemical), biological or radiation exposure. 9. Entitlement to service connection for actinic keratosis and skin cancer, to include as due to herbicides (chemical), biological or radiation exposure. 10. Entitlement to service connection for diabetes mellitus, type II, to include as due to herbicides (chemical), biological or radiation exposure. 11. Entitlement to service connection for memory disability, to include as due to herbicides (chemical), biological or radiation exposure. 12. Entitlement to service connection for liver disability and possible cirrhosis, to include as due to herbicides (chemical), biological or radiation exposure. 13. Entitlement to service connection for urinary disability, including kidney cysts, to include as due to herbicides (chemical), biological or radiation exposure. 14. Entitlement to service connection for prostate disability, to include as due to herbicides (chemical), biological or radiation exposure. 15. Entitlement to service connection for right leg disability, to include as due to herbicides (chemical), biological or radiation exposure, and as secondary to service-connected chronic muscular strain superimposed on degenerative instability with sciatica. 16. Entitlement to service connection for left knee disability, to include as secondary to service-connected chronic muscular strain superimposed on degenerative instability with sciatica. 17. Entitlement to service connection for right hip disability, to include as secondary to service-connected chronic muscular strain superimposed on degenerative instability with sciatica. 18. Entitlement to service connection for sleep apnea, to include as secondary to service-connected disabilities. 19. Entitlement to special monthly compensation based on the need for regular aid and attendance or at the housebound rate. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. N. Moats, Associate Counsel INTRODUCTION The veteran had active duty service from September 1958 to August 1960. The issues of service connection for actinic keratosis and skin cancer, diabetes mellitus, type II, and right leg disability come before the Board of Veterans' Appeals (Board) on appeal from a February 2002 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). A notice of disagreement was received in June 2002. The issues of service connection for chest tumor with blood spots, abdomen and shoulder tumor, neuralgia, pancreas disability, persistent cough, severe joint pain, peripheral neuropathy, urinary disability and prostate disability come before the Board on appeal from a July 2003 rating decision by the RO. A notice of disagreement was received in July 2003. A statement of the case was issued in February 2004 with respect to all of these issues, and a substantive appeal was received in March 2004. The issue of an increased rating for the veteran's service- connected low back disability comes before the Board on appeal from a March 2004 rating decision by the RO. A notice of disagreement was received in April 2004, a statement of the case was issued in April 2005, and a substantive appeal was received in April 2005. The issues of service connection for memory disability, liver disability and possible cirrhosis, left knee disability, right hip disability and sleep apnea as well as the issue of special monthly compensation comes before the Board on appeal from a July 2005 rating decision by the RO. A notice of disagreement was received in September 2005, a statement of the case was issued in November 2006, and a substantive appeal was received in November 2006. In his substantive appeals, the veteran requested a Board hearing at the local RO. A Board hearing was scheduled in September 2007; however, the veteran subsequently cancelled the hearing and has not submitted a motion requesting to reschedule. The veteran submitted additional evidence to the Board in October 2007. However, the majority of the evidence submitted is either redundant or duplicative of evidence already of record. Significantly, the Board notes that the veteran submitted an October 2007 newspaper article not previously of record. Nevertheless, as discussed in more detail below, since the veteran was not exposed to radiation in service, the Board finds that this article is not pertinent to the instant claim. In sum, waiver of RO consideration of all the additional evidence is not necessary. 38 C.F.R. § 20.1304(c). Further, at times, the veteran appears to be claiming that he had active duty service until 1964. However, the veteran's service personnel records, including his DD 214, as well as an Honorable Discharge certificate, clearly show that the veteran was discharged from active service in August 1960 and from reserve duty in August 1964. The issues of service connection for severe joint pain, actinic keratoses and skin cancer, urinary disability, prostate disability, right leg disability, left knee disability, right hip disability and sleep apnea as well as entitlement to special monthly compensation 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. The veteran's service-connected chronic muscular strain superimposed on degenerative instability with sciatica is manifested by pain, degenerative changes and limitation of motion, but not by incapacitating episodes of intervertebral disc syndrome totaling at least six weeks in duration during any year, ankylosis, or any associated neurological impairment. 2. The veteran did not serve in the Republic of Vietnam during active service, and exposure to herbicides during his active service is not otherwise shown. 3. Chest tumor with blood spots was not manifested during the veteran's active duty service, nor is it otherwise related to such service. 4. Abdomen and left shoulder tumors were not manifested during the veteran's active duty service, nor are they otherwise related to such service. 5. Neuralgia was not manifested during the veteran's active service or for many years thereafter, nor is it otherwise related to such service. 6. Pancreas disability was not manifested during the veteran's active service, nor is it otherwise related to such service. 7. Persistent cough was not manifested during the veteran's active service, nor is it otherwise related to such service. 8. Peripheral neuropathy was not manifested during the veteran's active service or for many years thereafter, nor is it otherwise related to such service, including to herbicide exposure. 9. Type II diabetes mellitus was not manifested during the veteran's active service or for many years thereafter, nor is it otherwise related to such service, including to herbicide exposure. 10. Memory disability was not manifested during the veteran's active service, nor is it otherwise related to such service. 11. Liver disability and possible cirrhosis was not manifested during the veteran's active service or for many years thereafter, nor is it otherwise related to such service. CONCLUSIONS OF LAW 1. The criteria for a disability evaluation in excess of 40 percent for the veteran's service-connected chronic muscular strain superimposed on degenerative instability with sciatica have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.7, 4.71a, Diagnostic Codes 5237 - 5243 (2007). 2. Chest tumor with blood spots was not incurred in or aggravated by service. 38 U.S.C.A. §§ 501, 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.309, 3.311 (2007). 3. Abdomen and left shoulder tumors were not incurred in or aggravated by service. 38 U.S.C.A. §§ 501, 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.309, 3.311 (2007). 4. Neuralgia was not incurred in or aggravated by service, nor may it be presumed to have been incurred in or aggravated by service. 38 U.S.C.A. §§ 501, 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.311 (2007). 5. Pancreas disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 501, 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.309, 3.311 (2007). 6. Persistent cough was not incurred in or aggravated by service. 38 U.S.C.A. §§ 501, 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.309, 3.311 (2007). 7. Peripheral neuropathy was not incurred in or aggravated by service, nor may it be presumed to have been incurred in or aggravated by service. 38 U.S.C.A. §§ 501, 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.309, 3.311 (2007). 8. Type II diabetes mellitus was not incurred in or aggravated by service, nor may it be presumed to have been incurred in or aggravated by service. 38 U.S.C.A. §§ 501, 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.311 (2007). 9. Memory disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 501, 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.309, 3.311 (2007). 10. Liver disability and possible cirrhosis was not incurred in or aggravated by service, nor may it be presumed to have been incurred in or aggravated by service. 38 U.S.C.A. §§ 501, 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.311 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126; see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 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 record shows that in July 2001, October 2002, May 2003 and February 2005 VCAA letters, the appellant was informed of the information and evidence necessary to warrant entitlement to service connection. Moreover, a March 2006 letter to the veteran informed him of types of evidence necessary to establish an increased rating. The appellant was also advised of the types of evidence VA would assist him in obtaining as well as his own responsibilities with regard to identifying relevant evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). Lastly, the notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; (3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). As the March 2006 letter gave notice of the types of evidence necessary to establish a disability rating and effective date for the disabilities on appeal, the requirements set forth in Dingess have also been met. The Board also notes that the VCAA letters implicitly notified the appellant of the need to submit any pertinent evidence in his possession. In this regard, the appellant was repeatedly advised to identify any source of evidence and that VA would assist in requesting such evidence. He was advised to submit information describing the additional evidence or the evidence itself. The Board believes that a reasonable inference from such communication was that the appellant must also furnish any pertinent evidence that the appellant may have and that the requirements of 38 C.F.R. § 3.159(b)(1) have been met. The Board finds that all notices required by VCAA and implementing regulations were furnished to the appellant and that no useful purpose would be served by delaying appellate review to send out additional VCAA notice letters. With respect to the issue of an increased rating for the veteran's service-connected low back disability, section § 5103(a) requires, at a minimum, that VA notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). Further, if the Diagnostic Code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), VA must provide at least general notice of that requirement to the claimant. Additionally, the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life. As with proper notice for an initial disability rating and consistent with the statutory and regulatory history, the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation, e.g., competent lay statements describing symptoms, medical and hospitalization records, medical statements, employer statements, job application rejections, and any other evidence showing an increase in the disability or exceptional circumstances relating to the disability. Although not all of the requirements of Vazquez-Flores have been met in the instant case, the Board finds that any notice error did not affect the essential fairness of the adjudication because the March 2006 letter fully informed the veteran that he may submit medical evidence, lay observations and employment statements in support of his claim. Moreover, in his notice of disagreement and substantive appeal, the veteran specifically addressed the effect his disability had on his daily activities demonstrating that he had actual knowledge of the requirements for an increased rating. In Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007), the United States Court of Appeals for the Federal Circuit held that any error by VA in providing the notice required by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)(1) is presumed prejudicial, and that once an error is identified as to any of the four notice elements the burden shifts to VA to demonstrate that the error was not prejudicial to the appellant. VA can rebut this presumption by showing that the error did not affect the essential fairness of the adjudication. To do this, VA must show that the purpose of the notice was not frustrated, such as by demonstrating: (1) that any defect was cured by actual knowledge on the part of the claimant; (2) that a reasonable person could be expected to understand from the notice what was needed; or (3) that a benefit could not have been awarded as a matter of law. Sanders, 487 F.3d at 889. Additionally, consideration also should be given to "whether the post-adjudicatory notice and opportunity to develop the case that is provided during the extensive administrative appellate proceedings leading to the final Board decision and final Agency adjudication of the claim ... served to render any pre-adjudicatory section 5103(a) notice error non-prejudicial." Vazquez-Flores, supra. Thus, as the veteran had actual knowledge of the requirements for an increased rating and sufficient opportunity to submit evidence, despite the inadequate notice provided to him, the Board finds no prejudice to the appellant in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet.App. 384, 394 (1993). The United States Court of Appeals for Veterans Claims' decision in Pelegrini v. Principi, 18 Vet. App. 112 (2004) held, in part, that a VCAA notice as required by 38 U.S.C. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. Although the requirements set out in Pelegrini have not been satisfied with respect to all the issues on appeal, the deficiency in the timing of the VCAA notices was remedied by readjudication of the issues on appeal in the statements of the case and subsequent supplemental statements of the case. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Furthermore, the Board finds that there has been substantial compliance with the assistance provisions set forth in the law and regulations. The record in this case includes service medical and personnel records, VA treatment records, private treatment records and VA examination reports. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case and no further action is necessary. See generally 38 C.F.R. § 3.159(c)(4). No additional pertinent evidence has been identified by the claimant. The veteran was afforded a VA examination in January 2005 with respect to an increased rating for his low back disability. The examination report contains sufficient information to decide this issue on appeal. See Massey v. Brown, 7 Vet.App. 204 (1994). Thus, the Board finds that a further examination is not necessary with respect to this issue. As discussed in more detail below, with respect to the service connection issues being decided on the merits in this decision, a VA examination with nexus opinion is not required in order to make a final adjudication. In McLendon v. Nicholson, 20 Vet. App. 79 (2006), the Court held that, in disability compensation (service connection) claims, VA must provide a medical examination [for a nexus opinion, as applicable] 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. In this case, the probative evidence of record does not establish that the veteran suffered "an event, injury or disease in service," including exposure to herbicides, biological agents or radiation. More importantly, none of the evidence of record, including the veteran's own statements, establish either the presence of the claimed disorders (or pertinent symptoms) in service, or continuity of symptoms since service. Rather, the evidence first documents the claimed disorders many years after service, and the veteran himself does not contend that he noticed the disorders or any associated symptoms in service or thereafter; he maintains instead that he believes the disorders are related to certain service exposures. As a layperson, however, his opinion as to the etiology of his disorders (as opposed to his observations of his condition in service and thereafter) do not constitute competent medical evidence. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992). In the remand portion of the decision, the Board is requesting further development of the skin cancer claim with respect to radiation exposure. In theory, this development could show that he was in fact exposed to some degree of ionizing radiation in service. Even if, however, the evidence ultimately does demonstrate such exposure, there is still no "indication" that any such exposure resulted in the disorders at issue. Although the veteran has submitted some general articles concerning the effects of radiation, those articles do not even remotely address the veteran's particular situation, and in the Board's opinion are far too attenuated a link as to constitute an "indication" of a relationship to service in this case, even with the low threshold mentioned in McLendon. In short, the Board finds that there is no competent or credible evidence "indicating" a link between any current diagnosis of disability and the veteran's period of service. A VA examination as to the service connection issues decided herein is therefore not "necessary" under 38 U.S.C.A. § 5103A(d). For all the foregoing reasons, the Board concludes that VA's duties to the claimant have been fulfilled with respect to the issues on appeal. II. Increased Rating for Chronic Muscular Strain Superimposed on Degenerative Instability with Sciatica The present appeal involves the veteran's claim that the severity of his service-connected low back disability warrants a higher disability rating. Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service- connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. In the present case, it should also be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet.App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. The general rating formula for the spine provides for disability ratings under Diagnostic Codes 5235 to 5243, unless the disability rated under Code 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, for diseases and injuries of the spine, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Under the general rating formula for diseases and injuries of the spine, ratings are assigned as follows: a 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine; a 50 percent rating is awarded for unfavorable ankylosis of the entire thoracolumbar spine; and a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Note (1) to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Intervertebral disc syndrome (preoperatively or postoperatively) may be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. See 38 C.F.R. § 4.25 (combined ratings table). The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides that a 40 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. The evidence of record has been reviewed. Significantly, a May 2003 private letter by C.C., M.D. indicated that the veteran's sciatic symptomatology would have to be more directly related to his back. A private November 2003 X-ray study of the lumbar spine was submitted in March 2004, which was construed as a claim for an increased rating. The study showed severe degenerative disc disease, L3-4, L5-S1; and lower degenerative facet disease. In the March 2004 rating decision, the RO continued the veteran's current 40 percent disability rating. The veteran was afforded a VA examination in January 2005. The examiner noted that the veteran was a retired teacher. The veteran indicated that he could no longer teach because of back pain and impaired hearing. The veteran stated that he could operate a car for only about 90 minutes secondary to increasing pain in the back, right buttock and both shoulders. The veteran also stated that walking was limited to about 10 minutes by pain at the back and the knees. The veteran complained of pain over the entire thoracic and lumbar spine, worse at the low back, which radiated into his right buttock and thigh. The veteran also indicated that he had feelings of weakness and easy fatigue. Flare-up with activity bothered the back. Back flare-ups were usually with standing, walking, prolonged sitting, driving, etc. On physical examination, the examiner noted that the veteran was overweight, and muscle condition was average. The veteran was not able to rise on toes or heels. He complained of weakness and poor balance. He was able to flex forward and reach to the tibia. Percussion of the spine was painful at L5. Range of thoracolumbar motion testing disclosed 25 degrees flexion, 5 degrees extension, 15 degrees rotation (bilaterally), and 15 degrees lateral bending (bilaterally). In sitting position, rotation improved to 35 degrees. There was moderate back pain with these movements and there was guarding. The low back had milder tenderness at L5. There was no persistent muscle spasm. Reflexes were normal at the knees and ankles. Extensor muscles were unimpaired at the lower legs and feet. Sensation was diminished on all surfaces distal to the knees. Calf circumference was equal. Straight leg raising was limited to 65 degrees bilaterally by hamstring muscle tightness. Dorsiflexion of the foot did not cause any difficulty. The diagnosis was chronic muscular strain superimposed on degenerative instability. The examiner noted that the lumbar nerve roots were probably unimpaired and that the numbness in the distal portions of both lower extremities probably represented peripheral neuropathy likely related to diabetes. Lastly, the examiner opined that decreasing flexion of the back by 10 degrees represented symptoms at the back and decreasing flexion of the back by five degrees represented back flare-ups. The examiner also noted that the veteran had become a very poor candidate for heavier types of work and was limited to light work. The work needed to mostly be sitting and the veteran needed to be able to change positions as needed for comfort. The orthopedic portion of this work limitation was mostly because of his back. The examiner also indicated that the veteran was not utilizing bed rest in treatment for his back. VA treatment records showed complaints of low back and sciatic nerve pain, but do not demonstrate any associated neurologic impairment or ankylosis. They do not document any prescribed bed rest for intervertebral disc syndrome. A November 2005 VA examination for Aid and Attendance/Housebound showed that the veteran had decreased movement of his spine and trunk with forward flexion approximately 35 degrees. Lateral movements were decreased. Based on the medical evidence of record, the Board concludes that a rating in excess of 40 percent is not warranted. Under the general rating formula, 40 percent rating is the maximum rating based on limitation of motion. Moreover, where a musculoskeletal disability is currently evaluated at the highest schedular evaluation available based upon limitation of motion, a DeLuca analysis is foreclosed. Johnston v. Brown, 10 Vet. App. 80 (1997). Thus, since the veteran has been granted the maximum rating possible under the general rating formula for limitation of the lumbar spine, no higher rating based on the presence of functional loss due to pain, weakness, etc.. can be assigned. Further, there has been no medical evidence of unfavorable ankylosis of the thoracolumbar spine as to warrant assignment of a 50 percent rating under the general rating formula. Moreover, the medical evidence of record does not support a maximum rating of 60 percent under Diagnostic Code 5243 for intervertebral disc syndrome. Although the veteran has claimed numerous incapacitating episodes, the claims files are silent with respect to any objective findings of incapacitating episodes having a total duration of six weeks. They certainly do not document any prescription for bed rest. Significantly, the January 2005 VA examination specifically stated that the veteran was not using bed rest in the treatment of his back. With respect to neurologic abnormalities pursuant to Note (1) of the general rating formula for disease and injuries of the spine, there has been no objective finding of neurological abnormalities associated with the veteran's low back disability. Although the medical evidence does show that he has urinary and bowel problems, such as anal fissures, there is no competent medical evidence of record showing any bladder or bowel dysfunction associated with the veteran's low back disability. The January 2005 VA examination is silent with respect to any such findings. The Board recognizes that there has been medical evidence of sciatica; however, the January 2005 VA examiner indicated that the lumbar nerve roots were probably unimpaired and that any numbness in the lower extremities was probably related to nonservice-connected diabetes. Thus, the Board finds that a separate rating is not warranted for neurological symptoms, and the veteran's currently manifested symptoms associated with his low back disability are adequately contemplated in the current 40 percent rating. Therefore, based on the analysis above, the preponderance of the evidence is against entitlement to a rating in excess of 40 percent for the veteran's service-connected low back disability. As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt doctrine does not apply. See 38 C.F.R. § 4.3. The Board has, in compliance with Hart, supra, considered whether a higher rating was warranted during any discrete period of the appeal. The evidence of record is consistent, however, in showing the absence of ankylosis, incapacitating episodes of any significant duration, or associated neurologic impairment. The Board finds that the veteran is not entitled to assignment to a rating in excess of 40 percent for any portion of his appeal. The potential application of various provisions of Title 38 of the Code of Federal Regulations have also been considered but the record does not present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards." 38 C.F.R. § 3.321(b)(1). The veteran contends that he retired in part due to his lower back disorder, and the VA examiner noted that the veteran could not perform heavy labor. Notably, however, the examiner found that the veteran could perform light or sedentary work. In addition, the veteran has several nonservice-connected disorders, including diabetes, which clearly impact on his employment. The veteran has not adduced any convincing evidence supporting his opinion as to the impact of his lower back disorder on his last job or his employment in general. The Board points out that the assignment of a 40 percent disability evaluation is itself recognition of substantial impairment of employment. After reviewing the record, the Board finds that the evidence simply does not demonstrate marked interference with employment outside of that already contemplated by the assigned rating. Nor has the disorder necessitated frequent periods of hospitalization. Under these circumstances, the Board finds that the veteran has not demonstrated marked interference with employment so as to render impractical the application of the regular rating schedule standards. In the absence of such factors, the Board finds that criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet.App. 337 (1996); Shipwash v. Brown, 8 Vet.App. 218, 227 (1995). III. Service Connection Claims The veteran is claiming entitlement to service connection for chest tumor with blood spots, abdomen and left shoulder tumors, neuralgia, pancreas disability, persistent cough, peripheral neuropathy, diabetes mellitus, type II, memory disability and liver disability and possible cirrhosis. Specifically, the veteran is claiming that these disabilities are due to herbicide, biological or radiation exposure. Applicable law provides that service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Additionally, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as diabetes mellitus, cirrhosis of the liver, organic diseases of the nervous system, and malignant tumors, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may also 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). Service connection for disability that is claimed to be attributable to exposure to ionizing radiation during service can be demonstrated by several different methods. Davis v. Brown, 10 Vet. App. 209, 211 (1997); Rucker v. Brown, 10 Vet. App. 67, 71 (1997). First, there are certain types of cancer that are presumptively service connected, specific to "radiation-exposed veterans." 38 U.S.C.A. § 1112(c); 38 C.F.R. § 3.309(d). Second, when a "radiogenic disease" first becomes manifest after service, and it is contended that the disease resulted from exposure to ionizing radiation during service, various development procedures must be undertaken in order to establish whether or not the disease developed as a result of exposure to ionizing radiation. 38 C.F.R. § 3.311(a)(1). Third, even if the claimed disability is not listed as a presumptive disease under 38 C.F.R. § 3.309(d) or as a radiogenic disease under 38 C.F.R. § 3.311, service connection must still be considered under 38 C.F.R. § 3.303(d) in order to determine whether the disease diagnosed after discharge was incurred during active service. See Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994), reversing in part Combee v. Principi, 4 Vet.App. 78 (1993). Assuming that a person is a "radiation-exposed veteran" pursuant to 38 C.F.R. § 3.309(d)(3)(i), the diseases specific to such veterans for the purpose of presumptive service connection are the following: (i) leukemia (other than chronic lymphocytic leukemia); (ii) cancer of the thyroid; (iii) cancer of the breast; (iv) cancer of the pharynx; (v) cancer of the esophagus; (vi) cancer of the stomach; (vii) cancer of the small intestine; (viii) cancer of the pancreas; (ix) multiple myeloma; (x) lymphomas (except Hodgkin' s disease); (xi) cancer of the bile ducts; (xii) cancer of the gall bladder; (xiii) primary liver cancer (except if cirrhosis or hepatitis B is indicated); (xiv) cancer of the salivary gland; (xv) cancer of the urinary tract; (xvii) cancer of the bone; (xviii) cancer of the brain; (xix) cancer of the colon; (xx) cancer of the lung; and (xxi) cancer of the ovary. 38 C.F.R. § 3.309(d)(2). As to the second method for establishing service connection, the provisions of 38 C.F.R. § 3.311 provide for development of claims based upon a contention of radiation exposure during active service and post-service development of a radiogenic disease. The purpose of these provisions is to relieve claimants of the burden of having to submit evidence to show that their cancer may have been induced by radiation. These provisions do not give rise to a presumption of service connection, but rather establish a procedure for handling claims brought by radiation exposed veterans or their survivors. See Ramey v. Gober, 120 F.3d 1239, 1244 (Fed. Cir. 1997). The governing regulation essentially states that, in all claims in which it is established that a radiogenic disease first became manifest after service, and it is contended that the disease resulted from radiation exposure, a dose assessment will be made. 38 C.F.R. § 3.311(a). For purposes of 38 C.F.R. § 3.311, a "radiogenic disease" is defined as a disease that may be induced by ionizing radiation, that must become manifest five years or more after exposure. 38 C.F.R. § 3.311(b)(2)(i)-(xxiv), (b)(5)(iv). With respect to the first method, the Board notes that the veteran's claimed disabilities are not included as a presumptive disability for radiation-exposed veterans as set out under 38 C.F.R. § 3.309(d). Service connection under that regulation is therefore not warranted. As to the second method for establishing service connection, none of the disorders at issue are considered "radiogenic" under 38 C.F.R. § 3.311(b)(2). As to the third method for establishing service connection, the veteran claims that he was exposed to radiation during basic training as well as while he was stationed in France and Germany. Specifically, the veteran asserts that he was exposed to radiation from his duties as a heavy weapons infantry solder, a tank commander, a NATO missile instructor, a radiation pathfinder, and a chemical, biological, radiation trainee and trainer. The Board notes that the veteran's DD 214 and service personnel records showed that in November and December, 1958, the veteran completed the following training courses: SS-10 Missile Course; Battle Indoctrination; Code of Conduct; Military Justice; Geneva Convention; and CBR training. However, nothing in these records indicate that the veteran was exposed to radiation while completing these courses or any other time during his active duty service. Further, service medical records are silent with respect to any radiation exposure. In March 2003, the National Personnel Records Center indicated that no records of exposure to radiation for the veteran were available. In December 2002, the RO received confirmation from the Department of Defense that the veteran did not participate in Project 112/SHAD testing. The Board notes that in a May 2004 statement, another service member indicates that he worked at the "664 ordnance ammo pump for all disposal" in 1963 and that there was radiation material coming through from "Bomholder". However, this lay statement has no probative value as the veteran was no longer on active duty in 1963. The veteran also submitted a lay statement from his sister that provided that she believed his exposure to radiation and chemicals while he was in service caused the veteran many health problems. The sister is not competent to testify that the veteran was actually exposed to radiation while in service. In any event, even assuming that the veteran was exposed to radiation in service, there is no competent evidence linking his current disorders to such exposure. The veteran's own statements do not constitute competent medical evidence. While he has submitted several publications concerning radiation exposure and his disabilities, the information has minimal probative value because it does not purport or serve to link his current disabilities and service. See Sacks v. West, 11Vet. App. 314 (1998). In sum, service connection on a presumptive basis is not warranted, and there is no competent or credible evidence otherwise suggesting a link between the current disorder and any exposure to radiation therein. Thus, service connection for these disabilities as due to exposure to radiation is not warranted. For purposes of establishing service connection for a disability resulting from exposure to a herbicide agent, a veteran who, during active military, naval, or air service, served in the Republic of Vietnam between January 1962 and May 1975, shall be presumed to have been exposed during such service to a herbicide agent, absent affirmative evidence to the contrary demonstrating that the veteran was not exposed to any such agent during service. 38 U.S.C.A. § 1116(f). Moreover, the diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, with an exception not applicable to this case. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a)(6)(ii). These diseases include chloracne or other acneform disease consistent with chloracne, type II diabetes, Hodgkin's disease, multiple myeloma, Non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcoma. 38 C.F.R. § 3.309(e). In addition, the United States Court of Appeals for the Federal Circuit has determined that a veteran is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). The veteran's military personnel records show that he did not serve in the Republic of Vietnam at any time, and the veteran is not claiming otherwise. Rather, he contends that he was exposed to herbicides while stationed in Germany and France. The Board finds his account of exposure to herbicides, namely just that he knew herbicides were being sprayed, to lack credibility. In this regard, the Board points out that he has not explained in any persuasive detail just how he knew that herbicides were being sprayed. Nor do his records otherwise suggest that he was located in an area subject to herbicide spraying. The Board points out that as he did not service in Vietnam, he is not entitled to a presumption of exposure to herbicides, and that the evidence therefore must demonstrate such exposure. The Board finds his account to lack credibility. Moreover, while a July 2001 private letter from Dr. C.C. and a 2002 VA treatment record indicated that the veteran was exposed to Agent Orange and herbicides while in service, those reports are based on the unsubstantiated history provided by the veteran. The Board is not bound to accept medical opinions that are based on history supplied by the veteran, where that history is unsupported by the medical evidence. Black v. Brown, 5 Vet. App. 177 (1993); Swann v. Brown, 5 Vet. App. 229 (1993); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). Here, as there is no evidence to support the contention that the veteran was exposed to herbicides while in service, these medical records have no probative value when weighed against the veteran's service personnel records and his lack of service in Vietnam. Therefore, even though the veteran has been diagnosed with at least one of the enumerated disabilities listed under 38 C.F.R. § 3.309(e) (namely Type II diabetes, and arguably peripheral neuropathy), he is not presumed to have been exposed to herbicide agents because he was never in Vietnam and there is no record of any other herbicide exposure while in service. 38 U.S.C.A. § 1116(f). Thus, the Board finds that the presumptive regulations regarding exposure to Agent Orange are not applicable in this case. See 38 C.F.R. §§ 3.307(a)(6)(iii), 3.309(e). Further, the veteran appears to also assert his disabilities are due to some sort of exposure to biological warfare. However, again, the Board finds his account to lack credibility, both in light of the absence of corroboration in the service personnel and medical records, and also in the unpersuasive account of how this exposure purportedly occurred. Lastly, the Board finds that service connection for these disabilities is also not warranted under a direct theory of entitlement. The veteran's service medical records do not show any treatment or diagnosis of any of these disabilities. Further, the veteran's July 1960 service examination prior to discharge showed no abnormalities with respect to these disabilities. Further, in his contemporaneous medical history, the veteran does not indicate any problems associated with these disabilities. The first post service medical evidence of record are private treatment records from 1985, 35 years after discharge from active service, showing that the veteran had actinic keratoses. A May 1998 laboratory report showed that the veteran was diagnosed with basal cell carcinoma. Subsequent VA and private treatment records showed continuing treatment for actinic keratoses/skin cancer as well as treatment for diabetes mellitus and complaints of a chronic cough, joint pain and liver pain. An October 2004 private sonogram showed markedly increased echogenicity of the liver associated with nodular contour. The overall pattern was most consistent with cirrhosis, but differential diagnosis for increased echogenicity of the liver also included hepatitis and fatty infiltration of the liver. Current treatment records are for the most part silent with respect to the remaining disabilities. Nevertheless, importantly, none of the treatment records suggest a relationship to service. With respect to the veteran's assertions, medical evidence is generally required to establish a medical diagnosis or to address questions of medical causation; lay assertions of medical status do not constitute competent medical evidence for these purposes. See Espiritu. However, lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, No. 07-7029, slip op. at 7 (Fed. Cir. July 3, 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Here, the veteran is competent to say that he experienced symptoms while in service. However, the Board does not believe that the disabilities on appeal are subject to lay diagnosis. The veteran has not demonstrated that he has the expertise required to offer a nexus opinion between any current disabilities and service. Moreover, the Board finds his account of symptoms to otherwise lack credibility, given not only the absence of pertinent complaints or findings in service, but also the absence of any such complaints or findings for years after service. Thus, his statements have no probative value when weighed against his service medical records and the lack of treatment for many years. In sum, while the veteran's contentions have been carefully considered, these contentions are outweighed by the absence of any medical evidence to support the claim. With no evidence of any of these disabilities for at least 35 years after discharge from service and no competent medical evidence of record suggesting a link between the veteran's current disabilities and his active duty service, to include exposure to herbicides, biological agents or radiation, there is no basis for awarding service connection for these disabilities either on a direct basis or under the one-year presumption for diabetes mellitus, cirrhosis of the liver, organic diseases of the nervous system, and malignant tumors. Therefore, a preponderance of the evidence is against the veteran's claims for service connection for chest tumor with blood spots, abdomen and left shoulder tumors, neuralgia, pancreas disability, persistent cough, peripheral neuropathy, diabetes mellitus, type II, memory disability and liver disability with possible cirrhosis. As the preponderance of the evidence weighs against the claims, the benefit-of-the- doubt doctrine does not apply. See 38 U.S.C.A. § 5107(b). ORDER Entitlement to a rating in excess of 40 percent for chronic muscular strain superimposed on degenerative instability with sciatica is denied. Entitlement to service connection for chest tumor with blood spots is denied. Entitlement to service connection for abdomen and left shoulder tumors is denied. Entitlement to service connection for neuralgia is denied. Entitlement to service connection for pancreas disability is denied. Entitlement to service connection for persistent cough is denied. Entitlement to service connection for peripheral neuropathy is denied. Entitlement to service connection for Type II diabetes mellitus is denied. Entitlement to service connection for memory disability is denied. Entitlement to service connection for liver disability with possible cirrhosis is denied. REMAND The veteran is seeking entitlement to service connection for urinary disability, including kidney cysts, and prostate disability. The service medical records show recurrent dysuria as well as kidney trouble. At the time of discharge, examination revealed an inadequate meatal opening and urethritis. Current treatment records continued to show urinary problems, kidney cysts and prostatitis. Thus, given that there is evidence of urinary problems in service and evidence of current disabilities, the Board finds that the veteran should be afforded a VA examination to determine the nature, extent and etiology of any currently manifested urinary disability, including kidney cysts, and prostate disability. See 38 C.F.R. § 3.159(c)(4). Moreover, the veteran is also seeking service connection for right leg disability, left knee disability and right hip disability, to include as secondary to his service-connected low back disability. He is also claiming service connection for sleep apnea, to include as secondary to his service- connected disabilities. The Board finds that appropriate VA examinations with opinions are necessary to determine whether the veteran's right leg disability, left knee disability and right hip disability are proximately due to or aggravated by his service-connected low back disability; and whether the veteran's sleep apnea is proximately due to or aggravated by his service-connected disabilities. See 38 C.F.R. § 3.310 (2007). The veteran seeks service connection for actinic keratoses and skin cancer. In a September 2000 letter, Dr. R.O. indicates that he first saw the veteran in 1984 for actinic keratoses. He indicates that the veteran was diagnosed in April 1998 for basal cell carcinoma. He stated that actinic keratoses as well as basal cell carcinoma were thought to be due to skin injury from sun damage usually done in the first 20 to 25 years of life. He noted that the veteran reported a great deal of sun damage in his early years that continued while in the military. The doctor concluded that the sun damage experienced now by the veteran is from sun damage done in the first 25 years of his life (which, the Board notes, would encompass his period of service). In light of Dr. R.O.'s opinion suggesting that the veteran's keratoses and skin cancer may have resulted in some degree from sun exposure in service, the Board finds that a VA examination is necessary in this case. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); Douglas v. Derwinski, 2 Vet. App. 103 (1992). The Board also notes that skin cancer is a "radiogenic" disease under 38 C.F.R. § 3.311, and that the record shows the RO has not fully complied with that regulation, inasmuch as a radiation dose estimate was not obtained. The Board recognizes that the National Personnel Records Center indicated that it has no information for the veteran concerning radiation exposure, and that the Department of Defense has indicated that the veteran did not take part in a particular operation. Nevertheless, the veteran's DD Form 214 does confirm that he received chemical, biological and radiation training, and that he was trained in the use of the SS-10 missile system. The veteran contends that he served as a "radiation pathfinder" in service, that the SS-10 missiles sometimes used "dirty" warheads (i.e. contaminated with radiation), and that he was exposed to radiation while disposing of missile parts at a toxic ammunition dump. When a radiogenic disease first becomes manifest after service, and it is contended that the disease is the result of exposure to ionizing radiation in service, a radiation dose estimate will be obtained. For claims alleging radiation exposure on a basis other than presence during atmospheric nuclear weapons test participation or the occupation of Hiroshima or Nagasaki, Japan, a request will be made for any available records concerning the veteran's exposure to radiation. Any records obtained will then be forwarded to VA's Under Secretary for Health for preparation of a dose estimate. 38 C.F.R. § 3.311 (2007). Given the veteran's contentions, the Board finds that further development is required. The Board notes that, with respect to the issues of right leg disability, left knee disability, right hip disability and sleep apnea, it appears that the veteran has not received adequate notice pursuant to the VCAA. The Board notes that VCAA letters were sent to the veteran concerning what information and evidence was necessary to warrant entitlement to service connection under a direct theory of entitlement. However, the letters did not clearly set forth the type of information and evidence necessary to warrant entitlement to service connection under a secondary theory of entitlement pursuant to 38 C.F.R. § 3.310. On remand, the veteran should be provided with appropriate VCAA notice. In addition, although the veteran has received numerous VCAA letters with respect to the service connection issues on appeal, none of those letters specifically addressed the issue concerning severe joint pain. Pursuant to the Court's reasoning in Overton v. Nicholson, 20 Vet. App. 427 (2006) concerning the prejudicial effect of this lack of notice, the Board will remand the issue for proper VCAA notice. Lastly, the veteran also seeks entitlement to special monthly compensation based on the need for the regular aid and attendance of another person or on the basis of being housebound. However, as this issue is inextricably intertwined with the service connection issues being remanded, this issue must also be remanded and readjudicated by the RO in light of any additional development with respect to the service connection issues. Accordingly, the case is REMANDED for the following actions: 1. With respect to the issues of severe joint pain, right leg disability, left knee disability, right hip disability and sleep apnea, the RO should furnish the veteran with an appropriate VCAA letter. The letter should specifically include notice to the veteran of the evidence necessary to substantiate claims on both a direct basis, and on a secondary basis. The veteran should also be advised to submit any pertinent evidence in his possession. 2. The RO should forward a summary of the veteran's account of his radiation exposure to the Defense Threat Reduction Agency (or its successor organization, if appropriate) and request that agency to determine if the veteran was exposed to radiation in service, and to provide radiation dose information that specifically takes into account his allegations of such exposure. 3. Then, the RO should forward the veteran's claims folders to VA's Under Secretary for Health for preparation of a radiation dose estimate for the veteran in accordance with the requirements of 38 C.F.R. § 3.311 (a)(2)(iii) (2007). 4. The RO should then determine whether the veteran was exposed to radiation during service, and, if so, should undertake any other development required under 38 C.F.R. § 3.311, to include review by the Director of the Compensation and Pension Service. 5. The veteran should be afforded a VA examination for his urinary disability, including kidney cysts, and prostate disability. The claims files must be made available to the examiner for review. The examiner should clearly report all of the veteran's current urinary, kidney and prostate disabilities and offer an opinion as to whether it is at least as likely as not (i.e. a 50% or higher degree of probability) that any such disability is etiologically related to service. 6. The veteran should be scheduled for an appropriate VA examination for his right leg, left knee, and right hip disabilities. It is imperative that the claims files be made available to the examiner. The examiner should clearly delineate all current disabilities of the right leg, left knee and right hip. The examiner should respond to the following: a) Is it at least as likely as not (i.e. a 50% or higher degree of probability) that any current disabilities of the right leg, left knee and right hip are proximately due to, or caused by, the veteran's service- connected low back disability? b) Is it at least as likely as not that any current disabilities of the right leg, left knee and right hip have been aggravated by the veteran's service- connected low back disability? 7. The veteran should be scheduled for an appropriate VA examination for his sleep apnea. It is imperative that the claims files be made available to the examiner. The examiner should respond to the following: a) Is it at least as likely as not (i.e. a 50% or higher degree of probability) that the veteran's sleep apnea is proximately due to, or caused by, the veteran's service-connected disabilities? b) Is it at least as likely as not that the veteran's sleep apnea has been aggravated by the veteran's service- connected disabilities? 8. The veteran should be scheduled for an appropriate VA examination for his actinic keratoses and skin cancer. It is imperative that the claims files be made available to the examiner. Following examination of the veteran and review of the medical history, the examiner should provide an opinion as to whether it at least as likely as not (i.e. a 50% or higher degree of probability) that the veteran's actinic keratoses and/or skin cancer is(are) etiologically related to service, or was(were) manifest within one year of discharge from active service. 9. Thereafter, the RO should readjudicate the remaining issues on appeal. Unless the benefits sought are granted, the veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded an opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is notified by the RO. The veteran and his representative have the right to submit additional evidence and argument on the matters the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court 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). ______________________________________________ Thomas H. O'Shay Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs