Citation Nr: 1026591 Decision Date: 07/16/10 Archive Date: 07/28/10 DOCKET NO. 07-24 414A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for an acquired psychiatric disability other than posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for residuals of a stroke. 3. Entitlement to service connection for a skin disability, to include as secondary to herbicide exposure. 4. Entitlement to service connection for a low spine disability. 5. Entitlement to service connection for PTSD. 6. Entitlement to service connection for a lung disability, to include as secondary to asbestos exposure. 7. Entitlement to service connection for a stomach disability. 8. Entitlement to service connection for a bladder disability. 9. Entitlement to service connection for tooth loss, for compensation purposes. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD L. Jeng, Counsel INTRODUCTION The Veteran served on active duty from June 1963 to September 1965. This case comes before the Board of Veterans' Appeals (the Board) on appeal from a February 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) Indianapolis, Indiana. The decision below addresses the claims of service connection for PTSD, a lung disability, a stomach disability, a bladder disability, and toot loss for compensation purposes. The issues of whether new and material evidence has been received to reopen a claim of entitlement to service connection for an acquired psychiatric disability other than PTSD; and service connection for residuals of a stroke, a skin disability, and a low spine disability 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. As detailed in the remand section, the claim of service connection for an acquired psychiatric disability other than PTSD (characterized as an affective disorder with major depression) is properly construed as a claim to reopen rather than a new claim. The Veteran states that he has had problems with his teeth ever since his military service. He states that the dental bridge that he received during service fell out and he continues to have trouble with those teeth. In adjudicating the Veteran's tooth loss claim, the RO only addressed the issue as a claim for compensation purposes. The Board infers from the Veteran's statements a claim of service connection for a dental condition for the purpose of obtaining VA outpatient dental treatment. This claim is referred to the agency of original jurisdiction (AOJ) for additional referral to the appropriate Veterans Hospital Administration medical facility. See 38 C.F.R. § 17.161 (2009). The Board notes that a dental rating sheet was issued in April 1994 indicating that the Veteran may have already received VA outpatient dental treatment. FINDINGS OF FACT 1. The Veteran does not have PTSD related to his active military service. 2. The Veteran does not have a lung disability related to his active military service, including as a result of exposure to asbestos in service. 3. The Veteran does not have a stomach disability related to his active military service. 4. The Veteran does not have a bladder disability related to his active military service. 5. The Veteran has missing replaceable teeth or decayed restorable teeth; loss of substance of the maxilla or mandible, impairment of the mandible, or loss of a portion of the ramus or maxilla has not been shown. CONCLUSIONS OF LAW 1. PTSD was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 4.125 (2009). 2. A lung disability was not incurred in or aggravated by active military service, including asbestos exposure. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2009). 3. A stomach disability was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2009). 4. A bladder disability was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2009). 5. The criteria for service connection for a dental condition (tooth loss) for compensation purposes are not met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.381, 4.150 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist In correspondence dated in June 2005, November 2005, and June 2008, the RO satisfied VA's duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2010) and 38 C.F.R. § 3.159(b) (2009), in compliance with the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000). Specifically, the RO notified the Veteran of: information and evidence necessary to substantiate the claims; information and evidence that VA would seek to provide; and information and evidence that the Veteran was expected to provide. This notice included a request to submit information concerning any alleged PTSD stressors. In June 2008, the RO also notified the Veteran of the process by which initial disability ratings and effective dates are established. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Although the complete notice was not provided until after the RO initially adjudicated the Veteran's claims, the claims were properly re-adjudicated in June 2009, which followed the adequate notice. See Prickett v. Nicholson, 20 Vet. App. 370, 376-77 (2006). VA has done everything reasonably possible to assist the Veteran with respect to his claims for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c). Service treatment records have been associated with the claims file. All identified and available treatment records have been secured, including records obtained from the Social Security Administration and VA Medical Centers (VAMCs) in Fort Wayne, Indianapolis, and Marion, Indiana. Although the Veteran has not been provided examinations in conjunction with the claims not being remanded, medical examinations are unnecessary in this case because: there are no verified stressors (PTSD), there is insufficient evidence of an in-service event, injury, or disease (lung disability), there is insufficient evidence of the claimed disability or recurrent symptoms of such (stomach disability and bladder disability); and compensation may not be granted for the claimed disability (tooth loss). Under such circumstances, an examination is not required. See McLendon v. Nicholson, 20 Vet. App. 79 (2006) (noting that in initial service connection claims, VA must provide a VA medical examination when there is competent evidence of a current disability or persistent or recurrent symptoms of a disability). Thus, the duties to notify and assist have been met for these five claims. Analysis When seeking VA disability compensation, a veteran generally seeks to establish that a current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). "Service connection" basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. 38 C.F.R. § 3.303(a) (2009). Where chronicity of a disease is not shown in service, service connection may yet be established by showing continuity of symptomatology between the currently claimed disability and a condition noted in service. 38 C.F.R. § 3.303(b). PTSD The Veteran claims to have PTSD as a result of military service. A claim for service connection for PTSD requires (1) medical evidence establishing a diagnosis of the condition; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f) (2009); see Cohen v. Brown, 10 Vet. App. at 136-37 (1997). Section 4.125(a) requires the diagnosis to conform to the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). When the evidence does not establish that a veteran is a combat veteran, his assertions of service stressors are not sufficient to establish the occurrence of such events. Rather, his alleged service stressors must be established by official service record or other credible supporting evidence. 38 C.F.R. § 3.304(f); Pentecost v. Principi, 16 Vet. App. 124 (2002); Fossie v. West, 12 Vet. App. 1 (1998); Cohen, 10 Vet. App. at 128; Doran v. Brown, 6 Vet. App. 283 (1994). In this case, the Veteran indicated to VA clinicians that he engaged in combat. However, the evidence in the claims folder does not suggest that he engaged in combat. As a matter of law, a medical professional cannot provide supporting evidence that the claimed in-service events actually occurred based on a post- service medical examination. Moreau v. Brown, 9 Vet. App. 389, 395-96 (1996). In addition, the Veteran's own testimony, standing alone, will not be sufficient. Id. The Veteran's DD- 214 does not reflect that he received an award or medal indicative of combat participation. Additionally, there is no indication that the ship that the Veteran was assigned to, the USS Jenkins, participated in combat while the Veteran was aboard. Thus, the Board does not find that the Veteran engaged in combat with the enemy. While current treatment records show a diagnosis of PTSD, the Veteran has not articulated stressors which can be verified. The Veteran was provided letters by which he was requested to submit information regarding his stressors. At an August 2008 hearing before the RO, he indicated childhood stressors but did not discuss stressors directly related to service. The only possible stressors are gleaned from review of his post-service clinical records. A December 2005 VA treatment record noted that the Veteran reported cruelty and physical abuse during service. Also, an October 2006 VA treatment record noted that his in- service stressors included witnessing incoming fire and getting a letter from his wife that she had been raped by her father. At the hearing, he also indicated that his PTSD was due to working in the engine room during service and not being allowed to make something of himself. In any case, none of these alleged stressors are given with any level of specificity by which VA could verify his stressors through any research and records custodians such as the United States Army and Joint Services Records Research Center (JSRRC). Therefore, even though the Veteran has been diagnosed with PTSD, service connection would still be denied without a verified stressor. The Board further finds that, even if the Veteran's alleged in- service stressors were verified, service connection for PTSD would still be denied as the medical opinion evidence of record does not provide a nexus between current disability and service. Instead, in October 2006, a VA clinician stated that "[i]t is clear that his PTSD is not related to his service." In adjudicating this claim, the Board must assess the competence and credibility of the Veteran. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). In Barr v. Nicholson, 21 Vet. App. 303 (2007), the Court, citing Layno v. Brown, 6 Vet. App. 465, 467-69 (1994), emphasized that lay testimony is competent if it is limited to matters that the witness has actually observed and is within the realm of the witnesses personal knowledge; see also 38 C.F.R. § 3.159(a)(2) (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact- finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In this capacity, the Board finds the Veteran is competent to attest to his observations of his disorder. Layno, 6 Vet. App. at 467-69; 38 C.F.R. § 3.159(a)(2). However, as a lay person, he is not competent to diagnose a psychiatric disorder in accordance with DSM-IV or render an opinion as to the cause or etiology of any current disorder (i.e. that he currently has PTSD related to service) because he does not have the requisite medical expertise. See, e.g., Routen v. Brown, 10 Vet. App. 183, 186 (1997); Espiritu v. Derwinski, 2 Vet. App. 492 (1992). As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2009) Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Lung Disability The Veteran essentially contends that he has a lung disability related to military service, specifically to include due to asbestos exposure. There is no specific statutory or regulatory guidance with regard to claims for service connection for asbestos-related diseases. However, in 1988, VA issued a circular on asbestos-related diseases which provided guidelines for considering asbestos compensation claims. See Department of Veterans Benefits, Veterans Administration, DVB Circular 21-88-8, Asbestos-Related Diseases (May 11, 1988). The information and instructions contained in the DVB Circular have since been included in VA Adjudication Procedure Manual, M21-1, part VI, para. 7.21 (October 3, 1997) (hereinafter "M21-1"). Also, an opinion by the VA General Counsel discussed the development of asbestos claims. VAOPGCPREC 4-00 (April 13, 2000). The Board notes that the aforementioned provisions of M21-1 have been rescinded and reissued as amended in a manual rewrite (MR) in 2005. See M21-1MR, Part IV, Subpart ii, ch. 1, sec. H.29, entitled "Developing Claims for Service Connection for Asbestos- Related Diseases," and Part IV, Subpart ii, ch. 2, sec. C.9, entitled "Service Connection for Disabilities Resulting from Exposure to Asbestos." VA must analyze the Veteran's claim of entitlement to service connection for a lung disability under these administrative protocols using the following criteria. Ennis v. Brown, 4 Vet. App. 523, 527 (1993); McGinty v. Brown, 4 Vet. App. 428, 432 (1993). The latency period for asbestos-related diseases varies from 10 to 45 or more years between first exposure and development of disease. The exposure may have been direct or indirect, and the extent or duration of exposure is not a factor. M21-1MR, Part IV, Subpart ii, ch. 1, sec. H.29.a. The manual provisions acknowledge that inhalation of asbestos fibers and/or particles can result in fibrosis and tumors, and produce pleural effusions and fibrosis, pleural plaques, mesotheliomas of the pleura and peritoneum, and cancer of the lung, gastrointestinal tract, larynx, pharynx and urogenital system (except the prostate), with the most common resulting disease being interstitial pulmonary fibrosis (asbestosis). As to occupational exposure, exposure to asbestos has been shown in insulation and shipyard workers, and others. The clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal lung disease. M21-1MR, Part IV, Subpart ii, ch. 2, sec. C.9.a-f. The manual further provides that VA must determine whether military records demonstrate evidence of asbestos exposure in service; whether there is pre-service and/or post-service evidence of occupational or other asbestos exposure; and then make a determination as to the relationship between asbestos exposure and the claimed diseases, keeping in mind the latency and exposure information pertinent to the veteran. M21-1MR, Part IV, Subpart ii, ch. 2, sec. C.9.h. The Veteran's DD-214 shows that he was a boatswain's mate and he testified that he served onboard the USS Jenkins and cleaned the engine room. The Veteran's service treatment records do not show any treatment for, or complaints of, any lung disorders. Notably, the examination report at service discharge noted a normal lung and chest evaluation. A chest x-ray was also normal at that time. The Veteran currently has diagnoses of pleural thickening, pulmonary emphysema, and chronic scarring. Asbestos exposure and tobacco use are noted in the treatment records as well. After a careful review of the evidence of record discussed above, the Board finds that service connection for a lung disability, including as due to asbestos exposure, has not been established. Although inhalation of asbestos fibers can produce pleural effusion, the overall evidence does not reflect that the Veteran's current lung disabilities are related to his service. See M21-1MR, Part IV, Subpart ii, ch. 2, sec. C.9.a-f. In addition, the overall evidence does not reflect that the Veteran was exposed to asbestos in service. While the Veteran served on a ship during service, the record does not reflect that he was exposed to asbestos in service in his capacity as a boatswain's mate. This is not shown to be a military occupational specialty ordinarily exposing individuals with asbestos. The Veteran's declarations of exposure are not supported by any corroborative evidence in the form of other individuals similarly exposed or through any documentation submitted. The Veteran has not demonstrated how he would have the expertise to recognize its presence or his particular exposure. Therefore, the evidentiary record weighs against a finding that his currently diagnosed lung disabilities are causally related to any such exposure while in service or is otherwise related to service. The Veteran is competent to attest to his observations of his disabilities. Layno, 6 Vet. App. at 467-69; 38 C.F.R. § 3.159(a)(2). However, as a lay person, he is not competent to diagnose any medical disorder or render an opinion as to the cause or etiology of any current disorder (i.e. that he currently has a lung disability related to service) because he does not have the requisite medical expertise, particularly regarding any asbestos-related lung disability. See, e.g., Routen, 10 Vet. App. at 186; Espiritu, 2 Vet. App. at 492. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. Stomach Disability The Veteran contends that he has a stomach disability related to military service, specifically that he had lead removed from his body. Aside from complaints of stomach/abdominal pain, there is no current evidence of a stomach disability. The Board notes that pain alone, without a diagnosed related medical condition, does not constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). Congress has specifically limited entitlement to service- connected benefits to cases where there is a current disability. "In the absence of proof of a present disability, there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). See also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). Therefore, service connection for a stomach disability is not warranted. Even if the Veteran had a current diagnosis of a stomach disability, service connection would nevertheless be denied. Service treatment records, including the examination report at service discharge, are negative for any complaints or findings a stomach disability. Complaints of pain were noted 40 years after service discharge. In view of the lengthy period without treatment, there is no evidence of continuity of symptomatology and this weighs against the claim. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). The Veteran is competent to attest to his observations of his disability. Layno, 6 Vet. App. at 467-69; 38 C.F.R. § 3.159(a)(2). However, as a lay person, he is not competent to diagnose any medical disorder or render an opinion as to the cause or etiology of any current disorder (i.e. that he currently has a stomach disability related to service) because he does not have the requisite medical expertise. See, e.g., Routen, 10 Vet. App. at 186; Espiritu, 2 Vet. App. at 492. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. Bladder Disability The Veteran essentially contends that he has a bladder disability related to military service. He testified that he had blood in his urine and had a cyst taken off. Service treatment records, including the examination report at service discharge, are negative for any complaints or findings of a bladder disability. Post-service clinical records show that a November 1992 urogram revealed no abnormalities and the impression was a normal excratory urogram. Also, the Veteran reported blood in his urine in December 1992. A February 1993 VA examination report noted a diagnosis of hematuria. A private treatment report also dated in February 1993 noted that he had a history of blood in his urine but had no significant problems at that time; a history of hematuria which had resolved was noted. Significantly however, there is no current evidence of a bladder disability, or at least one since the 1990's. Congress has specifically limited entitlement to service- connected benefits to cases where there is a current disability. "In the absence of proof of a present disability, there can be no valid claim." Brammer, 3 Vet. App. at 225. See also Gilpin, 155 F.3d at 1353. Therefore, service connection for a bladder disability is not warranted. It appears from the medical evidence that the Veteran had hematuria. However, the competent medical evidence of record does not indicate that the Veteran has had hematuria at any time during the appeal period (the Veteran filed his claim of entitlement to service connection in May 2005). Cf. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that a current disability may be shown even though the disability resolves prior to the adjudication of the claim as long as a veteran has a disability at the time the claim is filed or during the pendency of the claim). The Veteran is competent to attest to his observations of his disability. Layno, 6 Vet. App. at 467-69; 38 C.F.R. § 3.159(a)(2). However, as a lay person, he is not competent to diagnose any medical disorder or render an opinion as to the cause or etiology of any current disorder (i.e. that he currently has a bladder disability related to service) because he does not have the requisite medical expertise. See, e.g., Routen, 10 Vet. App. at 186; Espiritu, 2 Vet. App. at 492. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. Tooth Loss The Veteran contends that during boot camp, he fell hitting his teeth. He indicated that he was subsequently sent to the dental clinic where he had three teeth pulled. Service treatment records show that at service enlistment, the Veteran was missing four teeth (numbers 1, 16, 19, and 32). Dental treatment records show that in August 1965, the Veteran had a bridge put in for tooth number 19 and teeth numbers 18 and 20 were used to anchor that bridge. Additionally, dental work was provided to treat other carious teeth. The examination report at service discharge confirms that a bridge was fixed from teeth numbers 18 to 20 and does not show any additional loss of teeth. Service connection for treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease will be considered service connected solely for the purpose of establishing eligibility for outpatient dental treatment in accordance with 38 C.F.R. § 17.161. See 38 C.F.R. § 3.381 (2009). Otherwise, dental disabilities are compensable for rating purposes under 38 C.F.R. § 4.150 (Schedule of ratings-dental and oral conditions). Such disabilities include impairment of the mandible, loss of a portion of the ramus, and loss of a portion of the maxilla. Compensation is available for loss of teeth only if such is due to loss of substance of body of maxilla or mandible. 38 C.F.R. § 4.150 (Diagnostic Codes 9900- 9916) (2009). Post-service medical records show that the Veteran has missing replaceable teeth or decayed restorable teeth. The evidence does not suggest, and he has not claimed, that he has loss of substance of the maxilla or mandible, impairment of the mandible, or loss of a portion of the ramus or maxilla. Here, the Veteran does not have a dental condition that may be service connected for compensation purposes. See 38 C.F.R. §§ 3.381, 4.150. All of his affected teeth are replaceable missing teeth or decayed restorable teeth, which may only be considered service connected for the purpose of establishing eligibility for outpatient dental treatment. As noted in the introduction, the issue of service connection for tooth loss for treatment purposes has been referred to the AOJ. The record does not suggest that the Veteran has missing teeth due to loss of substance of the maxilla or mandible. Consequently, service connection for tooth loss, for compensation purposes, is not warranted. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. ORDER Service connection for PTSD is denied. Service connection for a lung disability, to include as secondary to asbestos exposure, is denied. Service connection for a stomach disability is denied. Service connection for a bladder disability is denied. Service connection for tooth loss, for compensation purposes, is denied. REMAND As to the issue of service connection for an acquired psychiatric disability other than PTSD, the claim was previously denied in a March 1997 rating decision (then characterized as a neuropsychiatric condition). Thus, the claim is properly construed as a claim to reopen rather than a new claim. During the pendency of this claim, the Court issued Kent v. Nicholson, 20 Vet. App. 1 (2006), requiring notice of the evidentiary requirements necessary to reopen a previously-denied claim, and of what evidence would be new and material to reopen the claim. See 38 C.F.R. § 3.156 (2009). The Federal Circuit in, Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003), held that the regulation giving the Board direct authority to cure a procedural defect in an appeal by providing the claimant with notice under the VCAA, 38 C.F.R. § 19.9(a)(2)(ii), was invalid as contrary to the statutory authority, 38 U.S.C.A. § 5103(b). If the record has a procedural defect with respect to the notice required under the VCAA, this may no longer be cured by the Board. The Board must remand the case to the AOJ because the record does not show that the Veteran was provided adequate notice under the VCAA and the Board is without authority to do so. Here, although the RO sent VCAA notice letters to the Veteran in June 2005 and June 2008, they did not address the Veteran's claim as to whether new and material evidence has been submitted to reopen a previously denied claim for service connection for an acquired psychiatric disability other than PTSD as required by Kent. A remand is therefore needed in order to afford the Veteran with complete notice as cited in Kent. With regard to the issue of service connection for residuals of a stroke, the Veteran testified at his August 2008 hearing that his psychiatric symptoms resulted in his stroke. This issue is inextricably intertwined with the claim as to whether new and material evidence has been submitted to reopen a previously denied claim for service connection for an acquired psychiatric disability. In other words, if the claim for an acquired psychiatric disability is reopened and granted, this may impact the service connection claim for residuals of a stroke. See Smith (Daniel) v. Gober, 236 F.3d 1370, 1373 (Fed. Cir. 2001) (noting that where the facts underlying separate claims are "intimately connected," the interests of judicial economy and avoidance of piecemeal litigation require that the claims be adjudicated together); see also Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (finding that two or more issues are inextricably intertwined if one claim could have significant impact on the other). Action on the Veteran's claim for service connection for residuals of a stroke is therefore deferred. Nevertheless, the VCAA letter that is to be sent to the Veteran on remand must include notification of substantiating a claim of service connection on a secondary basis, notice of which he has not yet been sent. See 38 C.F.R. § 3.310 (2009). As to the claim for service connection for a skin disability, the Veteran essentially contends that he has a current disability related to military service, including herbicide exposure. The Veteran testified at his August 2008 hearing that he may have been exposed to herbicides while serving onboard a ship during service. However, the record is unclear whether he was exposed to herbicides during service (to include service in the Republic of Vietnam during the Vietnam era). As such, the record is insufficient upon which to render a full and fair determination at this time. VA has a duty to assist the Veteran in developing his claim, and on remand additional development in this regard should be carried out. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Additionally, review of the service treatment records show that the Veteran was seen on several occasions for skin rashes. In August 1963, he had a maculopapular rash on his face and trunk, and was diagnosed with rubella. In June 1965, he was seen for a skin rash with a four week history of pruritic rash in his groin area. In July 1965, the Veteran was seen for complaints of jock rash which he had for four months. Post-service clinical records also reflect treatment for various skin disabilities. VA's duty to assist includes a duty to provide a medical examination or obtain a medical opinion when it is deemed necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). See also McLendon, 20 Vet. App. at 79; Robinette v. Brown, 8 Vet. App. 69, 76 (1995). On remand, the Veteran should be afforded an examination to determine the etiology of any current skin disability even if exposure to herbicides is not established by the evidence. As to the claim for service connection for a low spine disability, the Veteran contends he has a current disability related to military service. He specifically asserts that he has a disability due to an accident in 1965. While service treatment records are negative for any complaints or findings of a low spine disability, post-service treatment records show that the Veteran has a current lumbar spine disability. These records show that the Veteran gave a history of injuring his spine onboard a ship during service wherein he was tossed into the air and landed on his spine (e.g., VA clinical record dated in August 2004). The clinical records also document that the Veteran indicated that his spine problems began in March 1993 which he attributed to his job as a prison guard (e.g., private treatment record dated in March 1993). On remand, the Veteran should be afforded an examination to determine the etiology of his current low spine disability. See McLendon, 20 Vet. App. at 79. It appears that the Veteran continues to receive regular treatment at the Fort Wayne, Indianapolis, and Marion VAMCs. Updated treatment records should be obtained in light of the remand. Accordingly, these issues are REMANDED for the following actions: 1. Provide the Veteran with a notice letter which complies with the notification requirements of the VCAA and Kent, for the claim of whether new and material evidence has been received to reopen a claim of entitlement to service connection for an acquired psychiatric disability other than PTSD. Also notify the Veteran of the information and evidence necessary to substantiate a claim of service connection on a secondary basis regarding the claim of service connection for residuals of a stroke. 2. Undertake all appropriate action to assist with the independent corroboration of the Veteran's claimed in-service exposure to herbicide agents during service, including, if warranted, by requesting relevant unit history information from the JSRRC. If it is determined the Veteran has not supplied the level of detail and information required for a meaningful search for corroborating evidence by the JSRRC, then there needs to be some express indication of this in the record and the Veteran appropriately notified (i.e. a formal finding). 3. Obtain the Veteran's more recent treatment records (since May 2009) from the Fort Wayne, Indianapolis, and Marion VAMCs and associate the records with the claims folder. 4. Schedule the Veteran for an examination to ascertain the nature and etiology of any current skin disability, including specifically, an assessment as to whether any current disability is etiologically related to military service, to include any herbicide exposure therein. (Advise the Veteran that failure to appear for an examination as requested, and without good cause, could adversely affect his appeal. See 38 C.F.R. § 3.655 (2009).) The claims file and a copy of this remand must be made available to and be reviewed by the examiner in conjunction with the examination. The examination report must indicate that the claims file was reviewed in conjunction with the examination. For any skin disability found, the examiner should provide an opinion as to whether there is a 50 percent probability or greater that it is causally or etiologically related to the Veteran's period of active service, to include the notations for rashes noted herein. The examiner should provide a rationale for the opinion provided and reconcile any opinion with any contradictory evidence of record. 5. Schedule the Veteran for an examination to ascertain the nature and etiology of any current low spine disability, including specifically, an assessment as to whether any current disability is etiologically related to military service. The claims file and a copy of this remand must be made available to and be reviewed by the examiner in conjunction with the examination. The examination report must indicate that the claims file was reviewed in conjunction with the examination. For any low spine disability found, the examiner should provide an opinion as to whether there is a 50 percent probability or greater that it is causally or etiologically related to the Veteran's period of active service, to include the Veteran's stated in-service injury. The examiner should provide a rationale for the opinion provided and reconcile any opinion with any contradictory evidence of record. 6. After the requested examinations have been completed, the reports should be reviewed to ensure that they are in complete compliance with the directives of this remand. If a report is deficient in any manner, it should be returned to the examiner. 7. Then, after ensuring any other necessary development has been completed, readjudicate the Veteran's claims remaining on appeal. If action remains adverse to the Veteran, provide him and his representative with a supplemental statement of the case and allow an appropriate opportunity to respond. Thereafter, the case should be returned to the Board. 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 VA. The Veteran 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 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. 2009). ______________________________________________ RYAN T. KESSEL Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs