Citation Nr: 1043247 Decision Date: 11/17/10 Archive Date: 11/24/10 DOCKET NO. 07-00 096 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for hypertension to include as secondary to service-connected diabetes mellitus. 2. Entitlement to service connection for ulcers due to herbicide exposure. 3. Entitlement to service connection for a heart condition (also claimed as heart surgery) to include as secondary to service- connected diabetes mellitus. 4. Entitlement to service connection for a right eye condition (also claimed as right eye bleeding). 5. Entitlement to service connection for bilateral hearing loss. 6. Entitlement to service connection for tinnitus. 7. Entitlement to an initial compensable evaluation for service- connected diabetic retinopathy. REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD D. M. Casula, Counsel INTRODUCTION The Veteran had active service from May 1964 to May 1966. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions dated in January 2006 and August 2006. In September 2007, the Veteran and his spouse testified at a Travel Board hearing at the RO, before the undersigned Veterans Law Judge. In November 2008, the Board remanded the issues listed on the title page herein to the RO via the Appeals Management Center (AMC) in Washington, DC, for further evidentiary development. The Board is satisfied that there has been substantial compliance with the remand directives set out in November 2008 as pertains to the issues currently on appeal. Stegall v. West, 11 Vet. App. 268 (1998). The Board notes that in September 2009, the AMC issued a supplemental statement of the case (SSOC) in this matter; however, the SSOC only dealt with five of the seven issues that the Board had remanded to the AMC. The other two issues, service connection for bilateral hearing loss and for tinnitus, were not encompassed in the September 2009 SSOC, nor were these issues otherwise addressed by the AMC. Since one of these issues will herein be allowed in part (service connection for left ear hearing loss) and the other issue will also herein be allowed (service connection for tinnitus), these issues need not be sent back to the AMC for issuance of an SSOC. The remaining claim for service connection for right ear hearing loss, however, must be remanded back to the AMC in order to be readjudicated and encompassed in an SSOC. Although further delay of this matter is regrettable, the issues of service connection for right ear hearing loss, for hypertension, and for a heart condition are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if additional action is required on his part. FINDINGS OF FACT 1. The competent medical and other evidence of record establishes that the Veteran's left ear hearing loss disability may be related to his period of active military service. 2. The competent medical and other evidence of record establishes that the Veteran's tinnitus may be related to his period of active military service. 3. The competent medical and other evidence of record establishes that the Veteran's right eye BRVO (branch retinal vein occlusion) may be related to his service-connected diabetes mellitus. 4. The preponderance of the competent evidence of record is against a finding that the Veteran has a right eye disability (other than BRVO and diabetic retinopathy) which may be related to service or to a service-connected disability. 5. The preponderance of the competent evidence of record is against a finding that the Veteran has ulcers which may be related to his active service or to herbicide exposure therein. 6. The competent medical evidence of record does not show clinical findings of diabetic retinopathy or that the Veteran has diminished visual acuity related to diabetic retinopathy. CONCLUSIONS OF LAW 1. Left ear hearing loss disability was incurred in active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2009). 2. Tinnitus was incurred in active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2009). 3. A right BRVO was shown to be due to or the result of the service-connected diabetes mellitus. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2009). 4. A right eye disability (other than BRVO and diabetic retinopathy) was not incurred in or aggravated by active service, and is not due to, the result of, or aggravated by a service- connected disability. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2009). 5. Ulcers were not incurred in or aggravated by active service, and are not due to or the result of exposure to herbicides in service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2009). 6. The criteria for an initial compensable rating for the service-connected diabetic retinopathy have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.7, 4.84a, Diagnostic Codes 6078, 6079 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating a claim for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1), as amended, 73 Fed. Reg. 23,353 (April 30, 2008). This notice must be provided prior to an initial decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The VCAA notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of disability; (3) connection between service and the disability; (4) degree of disability; and (5) effective date of benefits where a claim is granted. Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006). If complete notice is not provided until after the initial adjudication, such a timing error can be cured by subsequent legally adequate VCAA notice, followed by readjudication of the claim, as in a Statement of the Case (SOC) or Supplemental SOC (SSOC). Moreover, where there is an uncured timing defect in the notice, subsequent action by the RO which provides the claimant a meaningful opportunity to participate in the processing of the claim can prevent any such defect from being prejudicial. Mayfield v. Nicholson, 499 F.3d 1317, 1323-24 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The United States Court of Appeals for the Federal Circuit (Federal Circuit) previously held that any error in VCAA notice should be presumed prejudicial, and that VA must bear the burden of proving that such an error did not cause harm. Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). However, the United States Supreme Court (Supreme Court) has recently reversed that decision, finding it unlawful in light of 38 U.S.C.A. § 7261(b)(2), which provides that, in conducting review of a decision of the Board, a court shall take due account of the rule of prejudicial error. The Supreme Court in essence held that - except for cases in which VA has failed to meet the first requirement of 38 C.F.R. § 3.159(b) by not informing the claimant of the information and evidence necessary to substantiate the claim - the burden of proving harmful error must rest with the party raising the issue, the Federal Circuit's presumption of prejudicial error imposed an unreasonable evidentiary burden upon VA and encouraged abuse of the judicial process, and determinations on the issue of harmless error should be made on a case-by-case basis. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). In a claim for increase, the VCAA requirement is for generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, No. 08-7150, 2009 WL 2835434 (Fed. Cir. Sept. 4, 2009). In this case, the VCAA duty to notify was satisfied by way of letters sent to the Veteran in October 2005, May 2006, and December 2008 that fully addressed the notice elements in this matter. These letters informed the Veteran of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. Because the Veteran's diabetic retinopathy claim arises from his disagreement with the initial rating assigned following the grant of service connection, additional notice is not required and any defect in the notice is not prejudicial as the Courts have held that once service connection is granted the claim is substantiated. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice under VCAA is needed regarding any of the claims on appeal. The Board also notes that in the aforementioned letters dated in May 2006 and December 2008, the Veteran was advised of how disability ratings and effective dates are assigned. See Dingess v. Nicholson, supra. Moreover, he has not demonstrated any error in VCAA notice, and therefore the presumption of prejudicial error as to such notice does not arise in this case. See Sanders v. Nicholson, supra. Thus, the Board concludes that all required notice has been given to the Veteran. The Board notes that the Veteran was not scheduled for a VA examination to determine whether he has ulcers that may be related to service or to exposure to Agent Orange in service. Pursuant to 38 C.F.R. § 3.159(c)(4), VA will provide a medical examination or obtain a medical opinion based upon a review of the evidence of record if VA determines it is necessary to decide the claim. A medical examination or medical opinion is necessary if the evidence of record does not contain sufficient competent medical evidence to decide the claim but (1) contains competent lay or medical evidence of a current diagnosed disability or persistent or recurrent symptoms of disability; (2) establishes that the veteran suffered an event, injury, or disease in service; and (3) indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service. The third part could be satisfied by competent evidence showing post- service treatment for a condition or other possible association with military service. As delineated in 38 C.F.R. § 3.159(c)(4), a VA examination to address the question of etiology as related to service is required when the veteran presents a claim for service connection in which there was a pertinent event, injury, or disease in service; there is evidence of current disability; the medical evidence of record does not contain sufficient competent medical evidence to decide the claim; and the veteran indicates that the claimed disability or symptoms may be associated with service. McLendon v. Nicholson, 20 Vet. App. 79 (2006). With regard to the claim for service connection for ulcers, the Board notes that the record does not contain competent medical evidence of a current ulcer disability. While the most recent VA treatment records addressing this issue, which are dated in 2001 and 2006 show that the Veteran had a history of ulcers and current dyspepsia, there is no finding of a current ulcer condition or disability. The Board recognizes that the Court has held that the presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). However, even if the Board allows that there is competent evidence of a current ulcer disability, the Board notes that there is no competent evidence of record (other than the Veteran's lay assertions) showing that any such ulcer disabilities may be related to service, including exposure to Agent Orange therein. Moreover, there has been no pertinent event, injury, or disease in service shown to which these disabilities might be related. Although he has contended that these disabilities are related to service, including Agent Orange exposure, his lay statements alone are not competent evidence to support a finding on a medical question (such as diagnosis or etiology) requiring special experience or special knowledge. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Thus, a VA examination on this issue is not warranted or necessary. The Board also finds VA has satisfied its duty to assist the Veteran in the development of the claims. The RO has obtained the Veteran's VA treatment records, and as explained above, a VA examination was not scheduled regarding the claim for service connection for ulcers. With regard to the claim for service connection for a right eye condition, the Board notes that the Veteran underwent VA examinations in December 2005, August 2006, and February 2009, and the Board finds that these VA examinations are adequate. Each examination included a review of the claims folders and a history obtained from the Veteran. Examination findings were reported, along with diagnoses/opinions, which were supported in the record. The examination reports are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 310-11 (2007). In addition, it appears that all obtainable evidence identified by the Veteran relative to his claims has been obtained and associated with the claims file, and that neither he nor his representative has identified any other pertinent evidence, not already of record, which would need to be obtained for a fair disposition of this appeal. It is therefore the Board's conclusion that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, supra. With regard to the claims for service connection for left ear hearing loss, tinnitus, and branch retinal vein occlusion, the Board notes that in view of the grants herein, there is no need for further discussion of notice or development as to those issues. Accordingly, the Board finds that VA has satisfied its duty to assist the Veteran in apprising him as to the evidence needed, and in obtaining evidence pertinent to his claims under the VCAA. Therefore, no useful purpose would be served in remanding this matter for yet more development. Such a remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit flowing to the Veteran. The Court has held that such remands are to be avoided. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). II. Service Connection Claims Service connection may be granted for disability which is the result of disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish service connection, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The existence of a current disability is the cornerstone of a claim for VA disability compensation. Degmetich v. Brown, 104 F.3d 1328 (1997); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board does recognize that the Court has held that the presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). In addition, the law provides that, where a veteran served ninety days or more of active military service, and certain chronic diseases, such as hypertension, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Secondary service connection may be established for disability which is proximately due to or the result of service-connected disability. 38 C.F.R. § 3.310(a); see Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Any increase in severity of a non- service-connected disease or injury that is proximately due to or the result of a service- connected disease or injury, and not due to the natural progress of the non-service-connected condition, will be service connected. However, VA will not concede that a non-service-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the non-service-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the non- service-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 C.F.R. part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). The Board notes that 38 C.F.R. § 3.310, above, the regulation which governs claims for secondary service connection, was amended during the pendency of this claim and appeal. The intended effect of this amendment is to conform VA regulations to the Allen decision, supra. 71 Fed. Reg. 52,744 (Sept. 7, 2006) (now codified at 38 C.F.R. § 3.310(b) (2009)). To whatever extent the revised regulation may be more restrictive than the previous one, the Board will afford the veteran review under both the old and new versions. See VAOPGCPREC 7-2003. 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. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). However, lay statements 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, 492 F.3d 1372 (Fed Cir. 2007); 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). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, 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 fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 1. Left Ear Hearing Loss and Tinnitus The Veteran contends that he has had hearing loss and tinnitus since service, resulting from exposure to excessive noise in service in his duties as a heavy equipment operator. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies at 500, 1000, 2000, 3000, or 4000 Hz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Even if disabling hearing loss is not demonstrated at separation, a veteran may establish service connection for a current hearing disability by submitting evidence that a current disability is causally related to service. Hensley v. Brown, 5 Vet. App. 155 (1993). On a VA examination in January 2009, the Veteran reported having two years on active duty as a heavy equipment operator. He reported military noise exposure, including weapons, heavy equipment, diesel engines, and power tools and chainsaws, without the use of hearing protection. He also reported deer hunting with a rifle one to two times a year, without the use of hearing protection. He indicated he drove a van for UPS for 30 years after service. He claimed that his hearing loss and tinnitus began in 1964. Audiological testing showed that the Veteran did not have auditory thresholds indicative of hearing loss disability, pursuant to 38 C.F.R. § 3.385, in either the right or the left ear. However, his speech recognition scores using the Maryland CNC Test were 90 percent in the left ear and 94 percent in the right ear. The examiner indicated that the Veteran's discharge examination was of questionable validity, but opined that because he had reported significant noise exposure that could begin high frequency sensorineural hearing loss, it was at least as likely as not that his hearing loss was due to or the result of military noise exposure and may have worsened as a civilian. The examiner also opined that it was at least as likely as not that the Veteran's tinnitus was related to his sensorineural hearing loss. It is not in dispute that the Veteran now has a left ear hearing loss disability by VA standards, as well as tinnitus. Based upon his reported working arrangements in service, it is also likely (and not in dispute) that he was exposed to, at least, some noise trauma in service. What he must still show to establish service connection for his hearing loss and tinnitus is that it is related to the noise trauma in service. In that regard, as noted above, the VA examiner in January 2009 opined, after reviewing the record, that hearing loss and tinnitus were at least as likely as not caused by or a result of the Veteran's military noise exposure. The Board finds no reason to question the opinion of the January 2009 VA examiner given her expertise as an audiologist, and that her opinion was based on extensive review of the claims file, and was accompanied by an explanation of rationale. As this competent evidence supports the Veteran's claim, the Board concludes that service connection for left ear hearing loss and for tinnitus is warranted. 2. Right Eye Condition The Veteran contends that he had a right eye bleed in the past, which was caused by his diabetes mellitus and which has left him with deteriorating right eye vision. A letter dated in March 2005 from a private physician and retina consultant, Dr. Sun, showed that the Veteran was seen for an examination which revealed branch retinal vein occlusion with cystoid macular edema, right eye; age-related macular degeneration in both eyes; cataracts in both eyes; and pre- existing hypertension and coronary artery disease, status post open heart surgery. Treatment records from Fort Leonard Wood eye clinic showed that in July 2005, the Veteran reported he had a broken blood vessel four months prior. His visual acuity, without glasses, was 20/40 in the right eye and 20/30 in the left eye. The assessment included branch retinal vein occlusion (BRVO) in the right eye; macular edema in the right eye; and age-related macular degeneration (ARMD) bilaterally. In March 2006, it was noted that the Veteran had an old BRVO in the right eye, with decreased visual acuity in the right eye. On VA examination in December 2005, the diagnoses included mild pigmentary retinopathy which did not affect the central visual acuity, which was noted to be excellent without correction; trace nuclear sclerotic cataract bilaterally, which was noted to be not visually significant; background diabetic retinopathy bilaterally, without neovascularization; and status post blepharoplasty of both eyes, with good lid position. The examiner indicated that by history, the Veteran had a vitreous hemorrhage, but there was no evidence of vitreous hemorrhage at the time of the examination and it was noted that the condition could resolve spontaneously. The examiner also indicated that the Veteran had no lasting visual sequelae from the condition, which happened in the past; however, it was likely that if he did have a vitreous hemorrhage, it was due to his diabetes. Finally, the examiner opined that it was unlikely that the Veteran's diabetes was the cause for any current visual loss. On a VA examination in August 2006, the Veteran reported a gradual decrease in right eye vision over the last six months, but had no complaints regarding left eye vision. He reported having a past episode of vitreous hemorrhage in the right eye, related to his diabetes mellitus, which apparently resolved on its own. Examination showed no evidence of background diabetic retinopathy. The impressions included diabetes mellitus with history of background diabetic retinopathy and vitreous hemorrhage right eye, with no evidence of retinopathy related to his diabetes on the current examination; age-related macular degeneration; and peripheral pigmentary degeneration unchanged. The examiner opined that there was no vision loss secondary to his diabetes, but that his macular degeneration with an apparent choroidal neovascular membrane had affected his central acuity in the right eye. A letter dated in December 2006 from a private ophthalmologist, Dr. Hainsworth, showed that the Veteran was seen at the University of Missouri Eye Clinic, and his visual acuity of the right eye was 20/400 and the left eye was 20/25. He was also noted to have macular degeneration with neovascular membrane of the right eye, with resultant visual decline. Dr. Hainsworth opined that the Veteran's visual acuity was likely to remain poor but stable on the right and indicated that glasses did not improve his vision on the right. On a VA examination in February 2007, it was noted that the Veteran's visual acuity on the right was 10/600 and 20/30 on the left, without correction. He pinholed at 20/20 on the left, but showed no improvement in pinhole in the right eye. On dilated fundus examination there was no diabetic retinopathy seen in either eye. The impressions included non-insulin-dependent diabetes mellitus without background diabetic retinopathy in both eyes; age-related macular degeneration, both eyes, with choroidal neovascularization; geographic atrophy of the retinal pigment epithelium in both eyes; history of branch retinal vein occlusion in the right eye; and mild nuclear sclerotic cataracts in both eyes. The examiner opined that the macular degeneration was not caused by or the result of diabetes. In support of his claim, the Veteran submitted a medical excerpt regarding retinal vein occlusion, and two medical excerpts regarding diabetic retinopathy. A private ophthalmic examination dated in February 2007, showed the Veteran's visual acuity, without glasses, was 20/400 in the right eye and 20/25 in the left eye. The assessment included retinal hemorrhage in the right eye, with history of BRVO in the right eye. A VA treatment record dated in February 2007, showed the Veteran had undergone an outside eye examination which showed retinopathy. It was noted that he had retinal hemorrhage OD, and he was instructed to return to Dr. Sun ASAP. In a letter dated in September 2007, Dr. Sun concurred with the Veteran's statement that his scar tissue in the macula in the right eye was a possible reason for his poor vision on the right side. A March 2008 VA treatment record showed the Veteran underwent a diabetic eye examination which revealed no apparent diabetes mellitus retinopathy, no diabetic complications, macular degeneration in both eyes, and cataracts in both eyes. On VA examination in February 2009, it was noted that the Veteran's diabetic retinopathy had an onset in 2005. Visual acuity testing of the right eye showed that uncorrected distant vision was 10/300 and corrected distant vision was 10/140, and near vision was not measurable for the right eye. The diagnoses included diabetes with no retinopathy in both eyes; exudative macular degeneration right eye with fibrotic scarring and status- post seven Avastin injections; history of BRVO right eye - resolved, no residual ocular or visual complications; and mild nuclear sclerosis cataracts both eyes. The examiner opined that there was no diabetic retinopathy noted on today's examination; that the exudative age-related macular degeneration was the cause of the Veteran's decreased visual acuity in the right eye, but that this was not caused by or a result of the Veteran's diabetes mellitus; that there was a history of branch retinal vein occlusion of the right eye that was resolved with no residual ocular or visual complications, and that this was at least as likely as not caused by or the result of the Veteran's service- connected diabetes mellitus; and that the mild nuclear sclerosis cataracts of both eyes were less likely as not caused by or a result of the Veteran's service-connected diabetes mellitus. Further, on the VA examination in 2009, the examiner explained that the diagnosis of diabetic retinopathy was made clinically, that there were no retinal findings of any kind (hemorrhages, microaneurysms, cotton wool spots, or neovascularization) noted on today's examination consistent with a diagnosis of diabetic retinopathy. The examiner opined that the exudative age-related macular degeneration was the cause of the Veteran's decreased visual acuity in the right eye, but that this was not caused by or a result of his diabetes mellitus, and that the mild nuclear sclerosis cataracts of both eyes were less likely as not caused by or a result of the service-connected diabetes mellitus. The examiner noted that age, heredity, race, hypertension, cardiovascular disease, smoking, and life-long exposure to sunlight ultra-violet radiation were all established etiologic factors of age-related macular degenerative. The examiner also explained that a BRVO occurs when a retinal venule at an arteriovenous crossing is compressed by a sclerosed arteriole, and that BRVOs have a strong association with systemic diseases, including hypertension, arteriosclerosis, diabetes, hypercholestermia, and hyperlipidemia. The examiner indicated that a significant amount of BRVOs resolve spontaneously, without treatment, though complications such as persistent macular edema and/or retinal neovascularization can occur. The examiner further noted that the Veteran was diagnosed with a BRVO in March 2005 that had resolved completely with no ocular or visual complications, and that the cause of this BRVO was at least as likely as not his diabetes mellitus as it was the precipitating factor in him ultimately being diagnosed with diabetes. The examiner opined that the BRVO, which had resolved, was in no way responsible for his right eye visual acuity loss. Finally, the examiner noted that the amount of cataracts present in the Veteran was normal for his age, and the examiner opined that it was less likely as not that the Veteran's mild nuclear sclerosis cataracts were caused by or a result of his diabetes mellitus. The record reflects that the Veteran has had at least two episodes of BRVOs, in 2005 and again in 2007. However, on the most recent VA examination in 2009, there was no evidence of a current BRVO or other retinopathy. Nonetheless, the fact that he did have two clinically noted BRVOs during the pendency of this appeal is arguably sufficient to show a current disability. In that regard, the Board recognizes the Court has held that the presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). With regard to whether the Veteran's history of BRVOs may be related to service or to a service-connected disability, the Board notes that on the VA examination in December 2005, the examiner opined that it was likely that if he did have a vitreous hemorrhage in the past, it was due to his diabetes. Likewise, in February 2009, the VA examiner opined that the cause of the Veteran's BRVO in March 2005 was at least as likely as not his diabetes mellitus as it was the precipitating factor in the Veteran ultimately being diagnosed with diabetes. Thus, based on the VA examiner's opinions, and resolving any reasonable doubt in favor of the Veteran, the Board concludes that the Veteran's history of BRVO was related to his service-connected diabetes mellitus. Therefore, service connection for BRVO is warranted. See 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, supra. Finally, the Board has also considered whether the Veteran may be entitled to service connection for any right eye condition (other than BRVO or diabetic retinopathy). In that regard, the competent medical evidence of record shows that the Veteran's right eye has also been diagnosed with macular degeneration and cataracts. What is needed in that regard, is competent medical evidence linking the Veteran's cataracts and/or macular degeneration to service or to the service-connected diabetes mellitus. In that regard, the Board notes that on the VA examination in 2009, the diagnoses included exudative macular degeneration of the right eye with fibrotic scarring and status- post seven Avastin injections, and mild nuclear sclerosis cataracts of both eyes. The examiner opined that the exudative age-related macular degeneration was the cause of the Veteran's decreased visual acuity in the right eye, but that this was not caused by or a result of his diabetes mellitus, and that the mild nuclear sclerosis cataracts of both eyes were less likely as not caused by or a result of the service-connected diabetes mellitus. The examiner explained that the age-related macular degeneration was a chronic degenerative disease resulting in damage to the macular photo-receptor cells, and that there was no medical evidence in the science literature linking exudative age-related macular degeneration to diabetes mellitus. The examiner also explained that the amount of cataracts present in the Veteran was very normal for his age, and opined that it was less likely as not that his mild nuclear sclerosis cataracts were caused by or a result of his diabetes mellitus. The Veteran also submitted an opinion, dated in February 2009, from a doctor at the VA eye clinic at Fort Leonard Wood, who examined the Veteran for complaints of right eye soreness. On examination, his best corrected acuities were 20/CF at 3 feet in the right and 20/25 in the left. He had nuclear sclerotic cataracts in both eyes, and an old BRVO in the right eye, which was at least as likely as not related to his hypertension. He also had macular degeneration in both eyes, which was progressively getting worse with time. The exact cause of the macular degeneration was unknown, but the doctor indicated that evidence had shown that a risk factor for developing macular degeneration was large exposure to ultraviolet light from the sun, as well as patients with fair skin and light iris colors who are also at higher risk. The doctor opined that due to the Veteran's military history "this could very well be a contributing factor to him developing macular degeneration in both eyes". It was also noted that a subretinal neovascular membrane was present, and visual acuities in the right eye had declined since 2006. Finally, it was noted he had no diabetic retinopathy present in either eye. The Board notes that the opinion received from the doctor at Fort Leonard Wood (that the Veteran's military history could very well be a contributing factor to him developing macular degeneration in both eyes) is, for all intents and purposes, inconclusive as to the origin of the Veteran's macular degeneration and cannot be employed as suggestive of a linkage between the disorder and military service. See Warren v. Brown, 6 Vet. App. 4, 6 (1993); Sklar v. Brown, 5 Vet. App. 104, 145-46 (1993). Opinions like this amount to "nonevidence," being neither for nor against the claim, because service connection may not be based on speculation or remote possibility. See generally Bloom v. West, 12 Vet. App. 185 (1999) (a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). The Board also notes that this opinion from the doctor at Fort Leonard Wood does not rise to the level of equipoise. See Chotta v. Peake, 22 Vet. App. 80, 86 (2008) (noting, in the context of an increased rating claim, that if the level of the appellant's disability . . . cannot be determined without resorting to speculation, then it has not been proven to the level of equipoise and a staged rating is not appropriate); see also 38 C.F.R. § 3.102 (when considering application of the benefit-of- the-doubt doctrine, reasonable doubt is one within the range of probability, as distinguished from pure speculation or remote possibility). A prior record from the Fort Leonard Wood eye clinic, as well as the VA examinations in 2006, 2007, and 2009, referred to the Veteran having age-related macular degeneration. Moreover, on the VA examinations in 2007 and 2009, the examiners opined that the Veteran's age-related macular degenerative was not related to his diabetes mellitus. Further, on the 2009 VA examination the examiner indicated that life-long exposure to sunlight ultra- violet radiation was one of the established etiologic factors for age-related macular degeneration. Likewise, a review of the claims folder shows that the opinions by the VA examiners in 2007 and 2009 were well reasoned, and that the 2009 VA examiner's opinion was based on a review of the relevant evidence and clinical evaluation. Thus, the 2009 VA examiner's opinion has the proper factual foundation and is, therefore, entitled to significant probative weight - especially in the absence of any opinion to the contrary. See Elkins v. Brown, 5 Vet. App. 474 (1993); Black v. Brown, 5 Vet. App. 177 (1993). And, while the Court has clarified that review (or lack of review) of the claims file is not dispositive of the probative value of a medical nexus opinion, such review is nonetheless deserving of consideration when, as here, there is relevant evidence in the claims file (such as the Veteran's medical history regarding his eyes) which may affect the nexus outcome offered by the examiner upon consideration of the evidence in the file. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board also recognizes the Veteran's contentions that he has a right eye condition (other than BRVO or diabetic retinopathy) related to service or the service-connected diabetes mellitus. Although the Veteran is certainly competent to offer his own opinion as to his eye problems and specifically, decreased visual acuity, over the years, and his lay statements may be competent 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, he is not competent, as a layperson, to render a medical opinion as to whether his macular degeneration is related to service or to a service-connected disability. Espiritu, supra. Eye disorders are complex conditions which require specialized training for determination as to diagnosis and causation, and are therefore not susceptible of lay opinions on etiology. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau, supra; Buchanan, supra. That is to say, the Board finds no basis for concluding that a lay person would be capable of discerning whether a current eye disability had an onset in service or is related to diabetes mellitus, in the absence of specialized training, and the Veteran has not established any specialized training for such qualifications. The preponderance of the evidence is therefore against the claim of service connection for a right eye condition (other than BRVO and diabetic retinopathy) on both a direct basis and as secondary to the service-connected diabetes mellitus. Consequently, the benefit-of-the-doubt rule does not apply and this claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 3. Ulcers The Veteran essentially contends that he has ulcers resulting from exposure to Agent Orange in Vietnam. With regard to this claim, the Board notes there is arguably competent medical evidence of a current disability. A VA treatment record dated in October 2001, showed that the Veteran had a past medical history of ulcers, and the current diagnosis was dyspepsia. A VA treatment record dated in August 2006 showed that he had dyspepsia and took medication for lower stomach acid. Thus, he arguably has had at least some type of ulcer condition. The Board recognizes the Court has held that the presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, supra. That holding, of course, did not abrogate the necessity of competent evidence of a nexus to service. The governing law provides that a "veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent . . . unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service." 38 U.S.C.A. § 1116(f). Thus, since the Veteran served in Vietnam, his exposure to Agent Orange may be conceded. The law further provides that, if a veteran was exposed to a herbicide agent during active service, presumptive service connection is warranted for the following disorders: 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 (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). Presumptive service connection for these disorders as a result of Agent Orange exposure is warranted if the requirements of 38 C.F.R. § 3.307(a)(6) are met. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.309(e). The Secretary of VA has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-346 (1994); see also 61 Fed. Reg. 41,442-41,449, and 61 Fed. Reg. 57,586- 57,589 (1996). The Secretary also clarified that a presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam Era is not warranted for several conditions, including lipid and lipoprotein disorders, gastrointestinal and digestive disease, immune system disorders, gastrointestinal tract tumors, and any other condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See Notice, 68 Fed. Reg. 27,630-41 (May 20, 2003). The Board notes that since the Veteran has not been diagnosed with a condition for which the Secretary specifically found a link to herbicide exposure, service connection for his ulcer condition cannot be presumptively granted based on herbicide exposure. When a disease is first diagnosed after service, but not within an applicable presumptive period, service connection may nevertheless be established by evidence demonstrating that disease was in fact incurred during service. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). If there is no presumptive service connection available, as is the case here, direct service connection can be established if the record contains competent medical evidence of a current disease process with a relationship to exposure to an herbicide agent while in service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303; Combee at 1043- 44. Where a veteran served ninety days or more of active military service, and certain chronic diseases, such as peptic ulcers, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). In that regard, service treatment records (STRs) show no report of or finding of any ulcers or ulcer condition. There is also no evidence of such disability during the one year presumptive period for such chronic disease. Moreover, the record reflects that an October 1975 private medical record from St. John's Hospital showed that the veteran was seen for complaints of abdominal pain. It was noted that in the past he had an x-ray proven duodenal ulcer, but he reported that his symptoms were not similar to the pain he experienced when he was having an active ulcer. In June 1979, it was noted that he had been hospitalized three or four years prior for a duodenal ulcer. An upper GI study dated in February 1985 showed a hiatal hernia and a slight deformity in the bulb and thickening of the folds in the duodenum consistent with acid peptic disease. An upper GI series taken in December 1988 showed a small hiatal hernia and that a gastric ulcer may be present, requiring gastroscopic examination. On examination in December 1988, the assessment was right upper quadrant discomfort with a long term history of peptic ulcer disease. In January 1989, it was noted that he had GERD with esophageal reflux pyrosis and an upper GI series in December 1988 demonstrated a hiatal hernia with free reflux and some mucosal changes suggesting esophagitis. Considering the fact that the record reflects that the Veteran was diagnosed with a shallow duodenal ulcer in October 1975, and at that time it was noted that in the past he had an x-ray proven duodenal ulcer, the Board notes that, generally, the fact of a long lapse of time between service separation in 1966 and initial findings some 9 years later weighs against the Veteran's claim. The Federal Circuit has determined that a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Moreover, what is missing from this case is competent evidence linking a current ulcer disability to service or to Agent Orange exposure therein. There is no competent evidence of record, other than the Veteran's lay assertions, showing any such relationship. Full consideration has been given to his own assertions that he has a current ulcer condition related to Agent Orange exposure; however, the Veteran is a layperson, and as such he has no competence to render a medical opinion on diagnosis or etiology of this condition. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992). It is true that the Veteran's lay statements may be competent to support a claim for service connection by supporting the occurrence of lay- observable events or the presence of disability or symptoms of disability susceptible of lay observation. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Here, exposure to Agent Orange is presumed by law. However, the Board does not believe that the existence of an ulcer condition and/or the probable etiology of an ulcer condition is subject to lay diagnosis. The Board finds no basis for concluding that a lay person would be capable of discerning the diagnosis of and the etiology of an ulcer condition, in the absence of specialized training, which, in this case, the Veteran has not established. Based upon the fact that the Veteran has not been shown to have an ulcer disability which has been associated with exposure to Agent Orange, upon the lack of clinical evidence that he had an ulcer condition in service, upon the remote onset of his duodenal ulcer years after service, and upon the lack of persuasive and probative medical evidence of a causal nexus between any current ulcer disability and service, the Board concludes that the Veteran is not entitled to service connection. As the preponderance of the evidence is against the claim, the benefit- of-the-doubt rule does not apply, and the claim for service connection for an ulcer condition must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). III. Initial Compensable Rating for Diabetic Retinopathy The Veteran seeks a higher disability evaluation for his diabetic retinopathy, which is currently evaluated as noncompensable. Such evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When rating the Veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, the current level of disability is of primary concern in a claim for an increased rating; and the more recent evidence is generally the most relevant in such a claim, as it provides the most accurate picture of the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55 (1994). That being said, VA's determination of the "current level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period that the increased rating claim has been pending. In those instances, it is appropriate to apply staged ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). As noted above, the Veteran is currently in receipt of a noncompensable disability rating for his service-connected diabetic retinopathy. The Veteran contends that he should be entitled to a compensable rating for his service-connected eye disability, as secondary to his diabetes mellitus. The Veteran is currently rated under Diagnostic Code 6079 for his service-connected diabetic retinopathy. A compensable rating for loss of visual acuity requires that corrected vision be 20/40 or worse in one eye and 20/50 or worse in the other. 38 C.F.R. § 4.84(a), Diagnostic Codes 6078, 6079. The ratings increase in 10 percent increments according to the levels of vision impairment with the greatest award of 100 percent assignable for visual acuity of 5/200 in each eye. 38 C.F.R. § 4.84(a), Diagnostic Codes 6063-6078. During the pendency of the appeal, the criteria for rating eye disabilities changed. However, because the Veteran filed his claim prior to December 10, 2008, the appeal will be considered under the old criteria. 73 Fed. Reg. 66543 (Nov. 10, 2008). The Board notes that the Rating Schedule does not contain a specific diagnostic code for diabetic retinopathy. However, where an unlisted condition is encountered it is permissible to rate it under a closely related disease or injury, in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2009). In this case, the Board finds that 38 C.F.R. § 4.84, DC 6006, which pertains to retinitis, is a closely analogous diagnostic code. Additionally, Diagnostic Codes 6000 through 6009, in chronic form, are to be rated from 10 percent to 100 percent disabling for impairment of visual acuity or loss of field of vision, pain, rest-requirements, or episodic incapacity, combining an additional rating of 10 percent during continuance of active pathology. A minimum rating of 10 percent is to be assigned during active pathology. 38 C.F.R. § 4.84, DCs 6000- 6009. On review of the determinative findings of record, the Board finds that the competent evidence of record continues to support the assignment of a noncompensable rating for diabetic retinopathy. Treatment records and VA examinations have continued to show no current findings of diabetic neuropathy, or any disability resulting from diabetic neuropathy, to include decreased visual acuity. Moreover, there have been no recent retinal findings of any kind that might be related to diabetic retinopathy. Rather, VA treatment records and VA examinations have determined that the Veteran's right eye decreased visual acuity is not related to his diabetes mellitus or to diabetic neuropathy, but rather has been related to other causes, including his age-related macular degeneration. The Board finds that the Veteran is not entitled to a compensable rating for loss of visual field, as on each examination he was found to have no visual field deficits related to diabetes or to diabetic neuropathy. 38 C.F.R. § 4.79, DC 6080. A 10 percent disability rating is warranted for impairment of central visual acuity in the following situations: (1) when vision in one eye is correctable to 20/50 and vision in the other eye is correctable to 20/40; (2) when vision in both eyes are correctable to 20/50; (3) when vision in one eye is correctable to 20/70 and vision in the other eye is correctable to 20/40; or (4) when vision in one eye is correctable to 20/100 and vision in the other eye is correctable to 20/40. 38 C.F.R. § 4.84a, DCs 6078, 6079. Based on the various eye examinations of the Veteran noted in the record, although it has been clearly shown that he has decreased and progressively worsening right eye visual acuity, at no time has any such decreased visual acuity been attributed to his diabetes mellitus or diabetic retinopathy. In addition, the Board finds that the record does not demonstrate pain, rest-requirements, or episodic incapacity, that would warrant a compensable rating. While a minimum rating of 10 percent is to be assigned during active pathology for some conditions, the evidence does not show that the Veteran has any active condition listed in Diagnostic Codes 6000 through 6009, that would warrant the assignment of a 10 percent rating. 38 C.F.R. § 4.84, Diagnostic Codes 6000-6009. The Board has also considered whether the record raises the matter of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2009). In exceptional cases where schedular ratings are found to be inadequate, consideration of an extraschedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities may be made. The governing norm in an exceptional case is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R § 3.321(b)(1). In this case, however, the Board finds that the rating schedule criteria are not inadequate. The Schedule provides for higher ratings for the Veteran's eye disability, but findings supporting a compensable rating have simply not been documented or alleged. In addition, it has not been shown that the service-connected diabetic retinopathy has required frequent periods of hospitalization or has produced marked interference with the Veteran's employment. Therefore, the Board finds that referral for consideration of the assignment of an extraschedular rating is not warranted. Finally, the Board has considered whether a higher rating might be warranted for any period of time during the pendency of this appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). However, the weight of the credible evidence demonstrates that the Veteran has not at any point during the appeal period been entitled to a compensable rating for his diabetic retinopathy. As the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for left ear hearing loss is granted. Service connection for tinnitus is granted. Service connection for right eye BRVO is granted. Service connection for a right eye disability (other than BRVO and diabetic retinopathy) is denied. Service connection for ulcers is denied. An initial compensable rating for the service-connected diabetic retinopathy is denied. REMAND Hypertension The Veteran essentially contends that his hypertension was caused by his service-connected diabetes mellitus, or alternatively was caused by his exposure to Agent Orange during his service in Vietnam. In support of his claim, he submitted a note from a private physician, dated in April 2006, in which the private physician opined that the Veteran's hypertension was "possibly related" to his diabetes. On VA examination in December 2005, the examiner indicated that the Veteran had hypertension long before the diagnosis of diabetes mellitus was made in 2005, and opined that based on this, there was no evidence to suggest that diabetes mellitus resulted in his developing hypertension. While there is medical evidence of record addressing whether the Veteran's diabetes mellitus caused or contributed to the Veteran's hypertension, the Board finds that such evidence is not definitive on this matter. Moreover, there has not been competent medical evidence addressing whether the Veteran's hypertension may be related to his presumed exposure to Agent Orange during his service in Vietnam. In that regard, the Board notes that in support of his claim, the Veteran's representative submitted a copy of an excerpt from Science Daily titled, "Data suggest link between Agent Orange exposure and hypertension". The Board concludes that the Veteran has submitted sufficient evidence which tends to show that he has current hypertension, and also medical evidence suggesting a link between hypertension and service. The Board therefore finds that the Veteran minimally meets the criteria for a medical examination under the VCAA and that the evidentiary record does not contain sufficient medical evidence to make a decision on his claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Thus, a remand for a VA examination and opinion is necessary in this matter. Heart Condition The record reflects that the Veteran has been diagnosed with coronary artery disease. A VA treatment record dated in March 2008 showed a diagnosis of arteriosclerotic coronary artery disease (ASCAD). It is unclear whether he may have ischemic heart disease, as suggested by his representative in the September 2010 informal hearing presentation. On October 13, 2009, in accordance with authority provided in 38 U.S.C.A § 1116, the Secretary of VA announced his decision to establish presumptions of service connection, based upon exposure to herbicides within the Republic of Vietnam during the Vietnam era, for three new diseases (or disabilities): ischemic heart disease, Parkinson's disease, and B cell leukemias. Effective August 31, 2010, the Secretary published a final rule amending 38 C.F.R. § 3.309(e) to establish a presumption of service connection for ischemic heart disease, Parkinson's disease, and B cell leukemias based upon exposure to herbicides used in the Republic of Vietnam during the Vietnam era. 75 Fed. Reg. 53,202. Although there was a stay of such claims previously in effect, effective October 30, 2010, the stay of the adjudication of the affected claims was lifted. Thus, on remand, a VA examination with opinion should be obtained in order to determine whether the Veteran has ischemic heart disease. Right Ear Hearing Loss As noted above, the claim for service connection for right ear hearing loss was not addressed by the AMC in an SSOC, thus, this issue must be remanded back to the AMC in order to be readjudicated and encompassed in an SSOC Accordingly, the case is REMANDED for the following action: 1. With any assistance needed from the Veteran, obtain updated and current treatment records for the Veteran, from both VA and private sources, for any treatment received related to hypertension, heart disease, cardiovascular disease, or right ear hearing loss. 2. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology/onset of any current heart disability, to include hypertension. All indicated tests and studies should be performed, and all clinical findings reported in detail. The claims folder must be made available to the medical examiner for review, and the examination report should indicate whether such review was performed. a. The examiner should specifically indicate whether the Veteran has ischemic heart disease. b. The examiner should be requested to offer an opinion as to whether it is more likely than not (i.e., to a degree of probability greater than 50 percent), at least as likely as not (i.e., a probability of 50 percent), or unlikely (i.e., a probability of less than 50 percent) that any current heart disability or cardiovascular disability, to include hypertension, is related to or aggravated by (i) service; (ii) the service-connected diabetes mellitus; or (iii) exposure to Agent Orange while serving in Vietnam. c. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. Note: The term "aggravated" in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. d. If it cannot be determined whether the Veteran currently has a heart disability, to include hypertension, that is related to his active service, to the service-connected diabetes mellitus, or to Agent Orange exposure, on a medical or scientific basis and without invoking processes relating to guesses or judgment based upon mere conjecture, the examiner should clearly and specifically so specify in the report, and explain why this is so. 3. Thereafter, readjudicate the issues on appeal, to specifically include the claim for service connection for right ear hearing loss. If any benefit sought on appeal is not granted to the Veteran's satisfaction, he and his representative should be provided with an SSOC and afforded the opportunity to respond thereto. The appellant has the right to submit additional evidence and argument on the 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 (CONTINUED ON NEXT PAGE) action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ______________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs