Citation Nr: 1121997 Decision Date: 06/07/11 Archive Date: 06/20/11 DOCKET NO. 05-30 071 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Whether new and material evidence has been received to reopen a previously denied claim for service connection for a disability manifested by hypoglycemia. 2. Entitlement to service connection for respiratory disorder, previously characterized as residuals of pneumonia, pleurisy and residuals of a blood clot. 3. Entitlement to service connection for diabetes mellitus (previously characterized as a disability manifested by hypoglycemia). 4. Entitlement to a compensable evaluation for hemorrhoids. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Murray, Associate Counsel INTRODUCTION The appellant is a veteran who served almost 21 years of active duty service ending with his retirement in June 2002. These matters are before the Board of Veterans' Appeals (Board) on appeal from September 2004 and October 2005 rating decisions of the Department of Veterans Affairs (VA) Regional Office in Waco, Texas (RO). In July 2008, a videoconference hearing was held before the undersigned acting Veterans Law Judge. A transcript of this hearing is of record. This case was before the Board in September 2008 when it was remanded for additional development. The issue of entitlement to service connection for diabetes mellitus (previously characterized as a disability manifested by hypoglycemia) is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. In June 2009 and July 2010 correspondence, the Veteran raised the issue of entitlement for increased rating for lumbar spine disability. This issue has not been adjudicated by the Agency of Original Jurisdiction (AOJ), and therefore, the Board does not have jurisdiction over it and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. In an unappealed December 2002 rating decision, the Veteran was denied service connection for a disability manifested by hypoglycemia (characterized as hypoglycemia). 2. The evidence associated with the claims file subsequent to the December 2002 rating decision includes evidence that relates to an unestablished fact necessary to substantiate the claim, is neither cumulative nor redundant of evidence already of record, and raises a reasonable possibility of substantiating the claim of entitlement to service connection for a disability manifested by hypoglycemia. 3. Any respiratory problems in service were acute and resolved with no residual disability at the time of separation; the Veteran's current mild restrictive pulmonary disorder is not etiologically related to his service. 4. Throughout the period of the appeal, the Veteran's hemorrhoids have been no more than moderate. CONCLUSIONS OF LAW 1. New and material evidence has been received to reopen a claim of entitlement to service connection for a disability manifested by hypoglycemia. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2010). 2. A respiratory disability was not incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2010); 38 C.F.R. § 3.303 (2010). 3. The criteria for a compensable rating for hemorrhoids have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.114, Diagnostic Code 7336 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2010), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2010), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. Although the regulation previously required VA to request that the claimant provide any evidence in the claimant's possession that pertains to the claim, the regulation has been amended to eliminate that requirement for claims pending before VA on or after May 30, 2008. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The Court further held that VA failed to demonstrate that "lack of such a pre-AOJ-decision notice was not prejudicial to the appellant, see 38 U.S.C. § 7261(b)(2) (as amended by the Veterans Benefits Act of 2002, Pub. L. No. 107-330, § 401, 116 Stat. 2820, 2832) (providing that '[i]n making the determinations under [section 7261(a)], the Court shall...take due account of the rule of prejudicial error')." The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Regarding the claim to reopen, inasmuch as the determination below constitutes a full grant of that portion of the claim, there is no reason to belabor the impact of the VCAA on this matter, since any error in notice timing is harmless. Regarding the remaining claims, the record reflects that the Veteran was provided all required notice by correspondence dated in September 2004, March 2006 and November 2008. Although the Veteran was not provided complete notice until after the initial adjudication of the claims, the Board finds that there is no prejudice to him in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that following the provision of the required notice and the completion of all indicated development of the record, the originating agency readjudicated the Veteran's claims. There is no indication in the record or reason to believe that the ultimate decision of the originating agency on the merits of the claim would have been different had complete VCAA notice been provided at an earlier time. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). Regarding VA's duty to assist, all appropriate development to obtain the Veteran's pertinent medical records, including service treatment records (STRs), has been completed. The Veteran has not identified any pertinent, outstanding records that could be obtained to substantiate his claims, including any records of post-service treatment. The Board is also unaware of any such records. Moreover, the Veteran has been afforded appropriate VA examinations and testified at a hearing. Accordingly, the Board concludes that VA has complied with its duty to assist the Veteran. Accordingly, the Board will address the merits of the claims. II. Law and Regulations Generally, a claim which has been denied by an unappealed RO decision may not thereafter be reopened and allowed based on the same record. 38 U.S.C.A. § 7105(c). However, under 38 U.S.C.A. § 5108, if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. See 38 C.F.R. § 3.303(b). The chronicity provision of 38 U.S.C.A. § 3.303(b) is applicable where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has such condition. Such evidence must be medical unless it relates to a condition as to which lay observation is competent. Savage v. Gober, 10 Vet. App. 488, 498 (1997). Service connection may also be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, including diabetes mellitus, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 C.F.R. §§ 3.307, 3.309(a). Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C.A. § 1155. Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. The degree of impairment resulting from a disability is a factual determination and generally, the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). However, staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The VA rating schedule evaluates external or internal hemorrhoids under 38 C.F.R. § 4.114, Diagnostic Code 7336. Under Diagnostic Code 7336, mild or moderate hemorrhoids are rated noncompensably (0 percent) disabling. A 10 percent rating is assigned if the hemorrhoids are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. 38 C.F.R. § 4.114 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). The Board notes that it has reviewed all of the evidence in the Veteran's claims files, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. III. Claim to Reopen The Veteran seeks to reopen a previously denied claim for service connection for a disability manifested by hypoglycemia. By an unappealed rating decision in December 2002, the RO denied service connection for hypoglycemia on the basis that there was no medical evidence that the Veteran had a disability associated with his hypoglycemia. Evidence considered at that time included: STRs, which show findings of hypoglycemia but no diagnosis of a disability manifested by hypoglycemia (including diabetes mellitus); and no post-service diagnosis of a disability manifested by hypoglycemia (including diabetes) related to service. Evidence received since the December 2002 rating decision includes private treatment records showing a diagnosis of diabetes mellitus. See March 2009 private treatment record from Dr. J. G. This evidence received since December 2002 is neither cumulative nor redundant of the evidence previously of record. At the time of the December 2002 rating decision, the evidence did not show any medical evidence of a disability associated with in-service and post-service findings of hypoglygemia. The evidence received since the December 2002 rating decision is new in that it was not previously of record. It is material in that it specifically relates to unestablished facts necessary to substantiate the claim for service connection and also raises a reasonable possibility of substantiating the claim. Resolving all doubt in favor of the Veteran, new and material evidence has been received, and the claim may be, and is, reopened. IV. Service Connection for Respiratory Disorder The Veteran maintains that he is entitled to service connection for a respiratory disorder, also claimed as residuals of pneumonia, residuals of a blood clot and pleurisy. He testified during a July 2008 Board hearing that he had what doctors in service thought was a spider bite on his leg. It was actually a blood clot in his leg that ultimately traveled to his lung and caused breathing problems. The Veteran also testified that he had pneumonia in service, and continues to have breathing problems to this day. The Veteran's STRs are negative for complaints, treatment, or diagnosis of a chronic respiratory disorder in service. March 2001 and February 2002 chest X-ray reports are negative for cardiopulmonary disease. An April 2002 report of medical history shows that the Veteran intended to seek VA disability compensation for several disorders, but a respiratory disorder was not included in these. Approximately one week after his retirement from service, the Veteran was seen with complaints of leg pain at Sheppard Air Force Base in June 2002. Follow-up examination in July 2002 shows that the Veteran was seen for a possible deep venous thrombosis (DVT) in his left leg and intermittent shortness of breath. A July 2002 ultrasound showed no evidence of a current DVT; however, it was felt that there was evidence of non-compressibility and decreased flow suggesting the possibility of a DVT. The Veteran continued to complain of lower extremity pain and upper right quadrant pain. A July 2002 chest X-ray report revealed evidence of low chest volume, but there was no evidence of acute infiltrate, pleural effusion or pneumothorax. August 2002 medical records show that the Veteran had right-sided pleurisy and pleural effusion as well as right lower lobe pneumonia. The report of an August 2002 private hospitalization summary shows that the Veteran was admitted for complaints of right-side pleuritic pain and pleural effusions. The Veteran was placed on an intravenous anticoagulatant to rule out a pulmonary embolus and a DVT. It was noted that the Veteran reported a history of left leg pain and swelling, and it was suspected that he had a clot near his ankle and it was non-compressible. A Doppler scan showed no evidence of a blood clot. During the Veteran's hospitalization, a CT scan report revealed evidence of right-side pleural effusion, but there was no evidence of clot. It was thought that the Veteran had possible pneumonia, and he was prescribed medication for treatment and then he was discharged. The examiner noted, "in light of symptomatic improvement in his symptoms as well as his history, I am still very suspicious that he may have had a deep venous thrombosis and pulmonary embolus back in the first part of July." A follow-up August 2002 private chest X-ray report showed evidence of an increase in right-sided pleurisy and pleural effusion, but a CT scan report showed no evidence of pulmonary emboli. It was still thought that the Veteran had a history that was suggestive of clots, even though, there was no demonstrable evidence shown in the diagnostic studies. He was given a steroid prescription to treat his symptoms. A subsequent follow-up chest X-ray report obtained a week later showed evidence of resolving pneumonia. A September 2002 treatment record shows the Veteran continued to complain of shortness of breath. The Veteran felt his symptoms were a continuation of his previous episode, and he wanted to continue treatment for steroids. Clinical findings continued to show build-up fluid in his lungs, and the Veteran was prescribed treatment for another two weeks. In October 2002, the Veteran was afforded a general VA examination for other claims that was pending at that time. The examination report shows that the Veteran had a normal lung evaluation. A February 2009 VA examination report notes the Veteran's medical history of suspected DVT, and his treatment for pleural effusion and pleurisy. It was noted that the Veteran currently complained of feeling congested, but he denied symptoms of coughing, shortness of breath, and pleuritic pain. Physical examination revealed lungs were clear with normal breath sounds without rubs. The chest X-ray studies were normal. The examiner noted that the pulmonary function studies indicated poor effort, and it was suggestive of restrictive pulmonary disease. The examiner stated the following: "[t]he Veteran as likely as not had a pulmonary embolus. He has not had any other episodes of pulmonary emboli or blood clots before that or since. There is as likely as not residual scarring." In a September 2009 addendum, the examiner clarified his findings from the February 2009 VA examination. The examiner stated that his opinion was that the Veteran more likely than not did have a pulmonary embolus and DVT in 2002, but there was no current residual damage from DVT, pleuritis, pneumonia, or pulmonary emboli. The examiner opined that the findings of mild restrictive pulmonary disease were likely due to obesity. In support of his conclusion, the examiner stated that there is no evidence of recurrent swelling in the left lower extremity or other symptoms that are consistent with residuals of a DVT. It was also noted that the Veteran has not had any recurrent episodes of pneumonia, pleuritic chest pain or breathing difficulty. There was no evidence of any residual damage from the blood clot or pleurisy that was secondary to the blood clot. The examiner lastly noted that "it is generally understood that pulmonary emboli do not cause significant residual damage in the lungs as they dissolve rapidly." Initially, the Board notes that the 2009 VA examiner opined that the Veteran did not have any current residual damage from DVT, pleuritis, pneumonia, or pulmonary emboli. There is no medical opinion to the contrary. One of the requirements for service connection is competent evidence that a claimed disability currently exists. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). Here, there is no current diagnosis of any residuals of DVT or pulmonary emboli. While cardiovascular disease may be eligible for presumptive service connection under 38 C.F.R. §§ 3.307 and 3.309, upon meeting the requisite criteria, here there is no evidence of current residual damage from the 2002 DVT and pulmonary emboli. Service connection is not warranted on this basis. Next, the Board finds that the preponderance of the evidence is against a finding that Veteran's current mild restrictive pulmonary disorder is related to service. There is no evidence of a restrictive pulmonary disorder shown in service. A review of the STRs shows that chest X-ray studies from February 2002, just prior to separation from service, revealed no abnormal findings. Further on the April 2002 medical history report, there was no indication that the Veteran had any respiratory problems at that time. The first evidence of mild restrictive pulmonary disorder is not shown until 2009. This evidentiary gap between the Veteran's active service (ending in April 2002) and the earliest objective medical evidence of restrictive pulmonary disorder (in February 2009) is evidence against a finding of continuity of symptomatology, and it weighs heavily against the claim. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd 230 F.3d 1330 (Fed. Cir. 2000) (service incurrence may be rebutted by the absence of medical treatment of the claimed condition for many years after service). Moreover, there is no competent medical evidence linking the Veteran's restrictive pulmonary disorder directly to service. The 2009 VA examiner concluded that the Veteran's restrictive pulmonary disorder was likely due to obesity. The examiner ruled out a link between his current disorder and the acute cardio-pulmonary disorders he experienced shortly after his discharge from service. There is no other medical opinion of record to contrary. The evidence does not support a finding that the Veteran's restrictive pulmonary disorder is directly related to service. See 38 C.F.R. § 3.303. The Board has considered the Veteran's statements that he has experience shortness of breath and difficulty breathing since 2002. The Board observes that lay people are competent to testify to visible or otherwise observable symptoms of disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). However, in this case, the Veteran's statements that he has a respiratory disorder that is related to his period of service concerns an etiological question as to an internal disorder, not a disease or an injury that is directly observable by a lay person. Compare Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis) with Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Barr, 21 Vet. App. at 308-309 (lay testimony is competent to establish the presence of varicose veins); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (lay person competent to testify to pain and visible flatness of his feet). The lay statements of the Veteran's statements concerning the etiology of his respiratory disorder are therefore not competent in this regard, and the Board has placed greater probative weight on the opinion proffered by the VA examiner that opined that the Veteran's restrictive pulmonary disorder is not related his cardio-pulmonary episode shortly after his discharge from service. The Board has considered the benefit of the doubt doctrine; as the preponderance of the evidence is against the Veteran's claims, that doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Accordingly, the claim must be denied. V. Compensable Evaluation for Hemorrhoids In this case, the Veteran has claimed entitlement to a compensable evaluation for hemorrhoids. He asserts that his disability is more severe than the symptomatology associated with a noncompensable evaluation. Historically, the Veteran's STRs show that he sought treatment for hemorrhoids on numerous occasions beginning in 1984. In December 1999, he underwent surgery with no complications. A December 2002 rating decision granted service connection for hemorrhoids, rated 0 percent. In February 2005, the Veteran submitted a claim for increased rating. A May 2005 VA examination report notes the Veteran's complaints that it was occasionally (twice a month) difficult to pass a stool. He denied any bleeding. The Veteran also complained of occasional rectal and perineal pain since about 2000. Digital rectal examination was negative. During the July 2008 Board hearing, the Veteran testified that his hemorrhoids had gotten worse since May 2005. He complained of gas but denied any bleeding. He stated that he used over the counter medication to treat his hemorrhoids. A September 2009 VA examination report notes the Veteran's complaints of difficulty passing gas. He denied bleeding or blood in his stool. The Veteran reported that he controls his bowel movements with diet. Upon physical examination, there was no evidence of external hemorrhoids or masses, bleeding or masses inside the rectum, tenderness or significant scarring. The Veteran was diagnosed with internal hemorrhoids, status post-hemorrhoidectomy, without residuals. The examiner noted that there was no evidence of hemorrhoids or history of treatment for hemorrhoids during the past three to four years. The examiner opined that the Veteran's complaints of constipation were not likely related to his history of hemorrhoids or treatment for hemorrhoids. Based on a review of the evidence of record, the Board concludes that the Veteran is not entitled to an increased rating for his hemorrhoids. A close review of the record reveals no distinct period during which the criteria for the next higher (10 percent) rating for hemorrhoids were met. See Hart, supra. For the period of the appeal, the Veteran was noted to have no more than small hemorrhoids; no evidence of bleeding was found. Certainly, there has been no objective evidence of large, thrombotic, or irreducible hemorrhoids, or of excessive redundant tissue. The evidence supports a conclusion that the Veteran's hemorrhoids have been no more than mild to moderate and, therefore, do not warrant a compensable schedular rating. The Board has also considered whether the case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(a). In determining whether a case should be referred for extra-schedular consideration, the Board must compare the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, the manifestations of the disability are contemplated by the schedular criteria. Therefore, referral for extra-schedular consideration is not in order. ORDER The appeal to reopen a claim of service connection for a disability manifested by hypoglycemia (diabetes mellitus) is granted. Service connection for respiratory disorder, previously characterized as residuals of pneumonia, pleurisy and residuals of a blood clot, is denied. A compensable evaluation for hemorrhoids is denied. REMAND With respect to the reopened claim of service connection for a disability manifested by hypoglycemia (here, diabetes mellitus), the Veteran has not been provided a VA examination in conjunction with his claim. The evidence of record indicates that the Veteran has a current diagnosis for diabetes mellitus. See private treatment record dated March 2009. A review of the Veteran's STRs shows findings of hypoglycemia. The Court has held that in disability compensation claims, VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service- connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim.). See McLendon v. Nicholson, 20 Vet. App. 79, 83(2006). On remand, the Veteran should be scheduled for a VA medical examination specifically for the purpose of determining whether the Veteran has diabetes mellitus that is etiologically related to his period of service, to include findings of hypoglycemia noted therein. See 38 U.S.C.A. § 5103A. Prior to any examination, any pertinent, outstanding, medical treatment records should be obtained. Accordingly, the case is REMANDED to the RO or the Appeals Management Center (AMC), in Washington, D.C., for the following actions: 1. With the Veteran's assistance, obtain any outstanding pertinent VA or private treatment records. 2. After all available records have been obtained, the RO or the AMC should schedule the Veteran for VA examination by the appropriate physician to determine the etiology of any current diabetes mellitus. The Veteran should be properly notified of the examination and of the consequences of his failure to appear. All studies deemed appropriate should be performed, and all the findings should be set forth in detail. The claims file should be made available to the examiner for review in conjunction with this examination. This fact should be so indicated in the examination report. After review of the claims file and examination, the examiner should offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran has diabetes mellitus that is etiologically related to his period of service. The examiner should be asked to comment on whether the hypoglycemia shown in service indicates the onset of diabetes mellitus. The examiner must explain the rationale for all opinions expressed. All findings and conclusions should be set forth in a legible report. 3. Then, the RO or the AMC should readjudicate the issue of entitlement to service connection for diabetes mellitus. If the benefit sought on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and provided an appropriate opportunity to respond before the claims file is returned to the Board for further appellate action. By this remand the Board intimates no opinion as to any final outcome warranted. No action is required of the appellant until he is otherwise notified but he has the right to submit additional evidence and argument on the matter that the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. T he law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). _________________________________________________ K. R. FLETCHER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs