Citation Nr: 1137423 Decision Date: 10/05/11 Archive Date: 10/11/11 DOCKET NO. 06-34 386A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to service connection for a chronic disability of the lower gastrointestinal tract, rectum, and anus (claimed as gastrointestinal bowel syndrome with diverticulitis, hemorrhoids, impaired sphincter control, and intestinal fistula with fecal discharge). 2. Entitlement to service connection for a chronic sinus disability, to include sinusitis and rhinitis. 3. Entitlement to service connection for a chronic cervical spine disability. 4. Entitlement to service connection for a bilateral acromioclavicular (AC) joint disability with muscle spasm of the shoulders. 5. Entitlement to service connection for a chronic lumbosacral spine disability. 6. Entitlement to service connection for hypertension. 7. Entitlement to service connection for a chronic left knee disability, claimed as arthritis. 8. Entitlement to service connection for a scar of the left side of the neck. 9. Entitlement to an initial evaluation above 10 percent for chronic laryngitis, status post vocal cord polyp, from February 15, 2006. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL The Veteran, his spouse Mrs. D.S., Mr. E.P., and Craig N. Bash, M.D. ATTORNEY FOR THE BOARD Bernard T. DoMinh, Counsel INTRODUCTION The Veteran served on active duty from July 1973 to June 1989. This matter comes to the Board of Veterans' Appeals (Board) on appeal from multiple rating decisions by the Baltimore, Maryland, Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran appeals a December 2004 rating decision that denied service connection for hypertension, arthritis, and a scar of the left side of the neck. Procedurally, the Board notes that in response to the Veteran's July 2005 notice of disagreement with respect to the aforementioned rating action, the RO furnished him with a statement of the case in October 2006. Although the claims file indicates that he did not file a timely substantive appeal of these issues by the December 2006 time limit, or otherwise submit new and material evidence pertinent to these denied claims, his appeal was subsequently "reactivated" by the RO in March 2007, in response to an inquiry from the Veteran's congresswoman. Although the Board is unaware of any provision in the law or regulations for VA to unilaterally "reactivate" a lapsed appeal, as this generous action by the RO will not result in harm or prejudice to the Veteran, the Board will respect the RO's decision and recognize the issues of entitlement to service connection for hypertension, scar of the left side of the neck, and arthritis as being on active appeal status and properly before the Board for appellate review. By way of further clarification, the Veteran has stated at his March 2011 hearing before the Board that his arthritis claim is for a chronic orthopedic disability of his left knee, which he claims as being due to arthritis. The Veteran also appeals an April 2007 rating decision which, inter alia, granted service connection for chronic laryngitis, status post vocal cord polyp, assigning an initial evaluation of 30 percent from December 21, 2005 (the date on which he filed his claim for service connection for this specific disability) to February 14, 2006, with a 10 percent evaluation effective February 15, 2006. As a point of clarification, this particular disability is rated under 38 C.F.R. § 4.97, Diagnostic Code 6516, using the criteria for evaluating chronic laryngitis. Diagnostic Code 6516 provides a maximum evaluation of 30 percent and no higher. In the Veteran's statements addressing this aspect of his appeal, he essentially contends that his chronic laryngitis, status post vocal cord polyp, warrants the maximum 30 percent evaluation and is contesting only that part of the RO's decision that reduced the initial evaluation from 30 percent to 10 percent, effective February 15, 2006. The Veteran also appeals that part of the April 2007 rating decision that denied service connection for a chronic lower gastrointestinal disorder. (In this regard, the Board notes that the RO mistakenly characterized this issue as an application to reopen this claim based on whether new and material evidence has been submitted. The Board has reviewed the relevant procedural history and finds that the Veteran had filed a timely notice of disagreement with respect to the original denial of the claim, followed by a timely substantive appeal upon issuance of a statement of the case. In any event, as the Board is allowing the VA compensation claim in this regard, there is no prejudice to the Veteran for the Board to address the issue as a service connection claim on the merits at the appellate level.) Also on appeal is an August 2008 RO rating decision which, inter alia, denied the Veteran's claims for VA compensation for hemorrhoids and a chronic sinus disability, to include sinusitis and rhinitis. An appeal is also taken of a November 2008 rating decision which, inter alia, denied service connection for a chronic disability of the rectum and anus manifested by impaired sphincter control and intestinal fistula with fecal discharge. (In the interests of simplifying and streamlining the appeal, the Board has consolidated the claims for multiple lower gastrointestinal and anorectal conditions. As will be further discussed below in the reasons and bases portion of this decision, the clinical evidence indicates that the claimed conditions are essentially manifestations of the same underlying chronic lower gastrointestinal disability.) Lastly, the Veteran appeals the determination of a January 2009 rating decision that denied service connection for a chronic cervical spine disability with neck muscle spasm, a bilateral AC joint disability with muscle spasm of the shoulders, and a chronic lumbosacral spine disability. The Veteran, accompanied by his representative and witnesses, submitted oral testimony and medical evidence in support of his appeal at a March 2011 hearing conducted at the VA Central Office in Washington, D.C., before the undersigned Veterans Law Judge. A transcript of this hearing has been obtained and associated with the Veteran's claims file for review and consideration by the Board. For the reasons that will be further discussed below in the remand portion of this decision, the issue of entitlement to an initial evaluation above 10 percent for chronic laryngitis, status post vocal cord polyp, from February 15, 2006, is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. The Veteran and his representative will be notified by VA if any further action is required on their part. FINDINGS OF FACT 1. Internal and external hemorrhoids and diverticular disease had their onset during active military service and the Veteran's current disabling conditions of his lower gastrointestinal and anorectal region (to include impaired sphincter control and intestinal fistula with fecal discharge) are attributable to hemorrhoids or the post-surgical residuals of multiple hemorrhoidectomies. 2. Allergic rhinitis and sinusitis had their onset during active military service. 3. Multilevel cervical spondylosis, osteoarthritis, and degenerative joint disease had their onset during active military service. 4. Bilateral AC joint osteoarthritis had its onset during active military service. 5. Arthritic spurring of the L4-L5 vertebrae with degenerative changes had its onset during active military service. 6. Hypertension had its onset during active military service. 7. Osteoarthritis of the left knee disability had its onset during active military service. 8. A scar of the left side of the neck did not have its onset during active military service. CONCLUSIONS OF LAW 1. Internal and external hemorrhoids and diverticular disease were incurred in active duty, and the current disabling conditions of the lower gastrointestinal and anorectal region (to include impaired sphincter control and intestinal fistula with fecal discharge) are attributable to in-service hemorrhoids or the post-surgical residuals of multiple hemorrhoidectomies. 38 U.S.C.A. §§ 1110, 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2010). 2. Allergic rhinitis and sinusitis were incurred in active duty. 38 U.S.C.A. §§ 1110, 1131, 1137 (West 2002); 38 C.F.R. § 3.303 (2010). 3. Multilevel cervical spondylosis, osteoarthritis, and degenerative joint disease were incurred in active duty. 38 U.S.C.A. §§ 1110, 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2010). 4. Bilateral AC joint osteoarthritis was incurred in active duty. 38 U.S.C.A. §§ 1110, 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2010). 5. Arthritic spurring of the L4-L5 vertebrae with degenerative changes was incurred in active duty. 38 U.S.C.A. §§ 1110, 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2010). 6. Hypertension was incurred in active duty. 38 U.S.C.A. §§ 1110, 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2010). 7. Osteoarthritis of the left knee was incurred in active duty. 38 U.S.C.A. §§ 1110, 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2010). 8. A scar of the left side of the neck was not incurred in active duty. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The VCAA and VA's Duty to Assist As will be further discussed below, the Veteran's claims of entitlement to service connection for chronic disability of the lower gastrointestinal tract, rectum and anus, a chronic sinus disability (to include sinusitis and rhinitis), a chronic cervical spine disability, a bilateral AC joint disability with muscle spasm of the shoulders, a chronic lumbosacral spine disability, hypertension, and arthritis of the left knee are being granted in full. Therefore, the Board finds that any error related to the Veterans Claims Assistance of Act of 2000 (VCAA) (Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified at 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2010)) with regard to these issues is rendered moot by this fully favorable decision. See 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159 (2010); Mayfield v. Nicholson, 19 Vet. App. 103, (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Thusly, there is no need to engage in any analysis with respect to whether the requirements of the VCAA have been satisfied concerning these particular matters on appeal. Service connection involves many factors, but basically means that the facts, shown by the evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if pre-existing 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) (2010). With chronic disability or disease shown as such in service (or within the presumptive period under 38 C.F.R. § 3.307 (2010)) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of skin irritation or sunburn in service will permit service connection for chronic skin carcinoma, first shown as a clear-cut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2010). Service connection may be granted for any disease diagnosed after discharge from active duty when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2010). Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2010). In this regard, the Board notes that the Veteran is presently service connected for recurrent major depression without psychosis, tinea versicolor, and chronic laryngitis, status post vocal cord polyp. Additionally, for veterans such as the current appellant, who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2010). If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing the second and/or third element of a service connection claim. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. See Savage, 10 Vet. App. at 495-98. When a veteran seeks service connection for a disability, VA is required to analyze and evaluate the supporting evidence in light of the places, types, and circumstances of service, as evidenced by service records; the official history of each organization in which the veteran served; the veteran's military records; and all pertinent medical and lay evidence. 38 U.S.C. § 1154(a) (West 2002); 38 C.F.R. § 3.303(a) (2010). It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102 (2010). (a.) Factual background and analysis: Entitlement to service connection for a chronic disability of the lower gastrointestinal tract, rectum and anus (claimed as gastrointestinal bowel syndrome with diverticulitis, hemorrhoids, impaired sphincter control, and intestinal fistula with fecal discharge). As relevant, the Veteran's service treatment records show that he was treated for complaints of recurring episodes of constipation and hemorrhoids during active duty due to a tight anal sphincter and fistula-in-ano. Current post-service VA and private medical records reflect that he continues to have a diagnosis of external and internal hemorrhoids, with a post-service history of a sphincterotomy and multiple surgical procedures to reduce the hemorrhoids. In a February 2009 lay witness statement from E.P., he reported that he was a fellow serviceman who personally knew the Veteran and served with him in 1973 - 1974, and 1987 - 1989. During service, he observed that the Veteran had problems performing his duties because of interference associated with ongoing health issues due to hemorrhoids. In August 2009, a VA physician examined the Veteran, reviewed his pertinent medical history, and diagnosed him with status post internal sphincterotomy and banding of internal hemorrhoid, history of fistula-in-ano while in service, with current complaints of anal pain and occasional fecal leakage, colon diverticulosis by barium enema in service without diverticulitis, and internal and external hemorrhoids, status post multiple prior hemorrhoidectomies. The VA examiner then presented the following nexus opinion, which states in pertinent part: I am asked my medical opinion if the current hemorrhoids, impairment of rectum or anus and anal sphincter, diverticular disease, and fistula-in-ano are related to the veteran's complaint of constipation during military service. The answer is [that they are] at least as likely as not caused by or [are] a result of constipation. Nonetheless, this constipation is related to a tight anal sphincter. . . noted while in the service, and. . . corrected by internal sphincterotomy. The constipation also in the past aggravated the symptoms of hemorrhoids. The veteran has. . . diverticular disease not complicated by diverticulitis. In an April 2010 statement, the Veteran's private medical consultant, Craig N. Bash, M.D., presented his medical credentials and qualifications and reported that he reviewed the Veteran's pertinent medical history and examined the Veteran. Afterward, Dr. Bash presented the following opinion: [The Veteran] had several hemorrhoids in service and has had several hemorrhoid surgeries, which have resulted in sphincter dysfunction and rectal fistula. It is my opinion considering every possible sound medical etiology/principle, to at least the 50% level of probability, that [the Veteran's] current rectal (hemorrhoids, fissure and sphinter [sic] dysfunction) problems are due to his experiences/trauma that the [Veteran] had during military service for the following reasons: He entered the service fit for duty without any doctor-diagnosed illnesses. He had hemorrhoids in service as is documented in his records and c-file. He had surgeries in 2004 and 2007 for his hemorrhoid problems which has [sic] resulted in his rectal dysfunction. He is incontinent of stool and this is likely due to. . . his rectal surgeries. His records do not support another more plausible etiology for his rectal problems other than his rectal hemorrhoid surgeries[.] The time lag between injury in service and current pathology is consistent with known medical principles and the natural history of this disease. No other physician has opined to the contrary. [Dr. Bash further opined that the Veteran's impaired sphincter was also secondary to a neurological component of his chronic low back disability. As previously stated, the Board is granting the Veteran service connection for internal and external hemorrhoids, status post multiple hemorrhoidectomies (and their associated disabling residuals), diverticular disease, and arthritic spurring of the L4-L5 vertebrae with degenerative changes. Thusly, while acknowledging that this part of Dr. Bash's opinion has high probative value favoring the Veteran's claim, the Board will not consider it further as it is conceding service connection on a direct basis.] In an April 2011 nexus opinion, Dr. Bash further stated: The [Veteran] had rectal surgery in service for hemorrhoids and has continu[ous] fissure-an-ano and constipation due to a tight rectal sphincter. It is my opinion along with the recent [VA] examiner opinion that [the Veteran's] rectal surgery contributes to his constipation and that his constipation aggravates his hemorrhoids. Thus he has loss of anal sphincter control due to his hemorrhoids and subsequent surgery. In view of the record discussed above, the Board finds that the weight of the clinical evidence tends to support a finding that the Veteran's multiple disabling conditions relating to his lower gastrointestinal tract, particularly his rectum and anus, had their onset in, or are otherwise etiologically attributable to his documented chronic constipation due to a tight sphincter, which had developed during active duty and caused or resulted in chronic internal and external hemorrhoids. The service-related hemorrhoids and the residuals of post-service surgeries associated with their treatment produced general impairment of his anorectal region. The clinical evidence also shows onset of the Veteran's diverticular disease in service, although no current diverticulitis. Although the Veteran claims entitlement to service connection for various symptomatic manifestations of his lower gastrointestinal/anorectal disability by history, his current established clinical diagnoses in this regard are internal and external hemorrhoids and diverticular disease. Therefore, resolving any doubt in the Veteran's favor, the Board will grant service connection for internal and external hemorrhoids, status post multiple hemorrhoidectomies (and their associated disabling residuals), and diverticular disease. (b.) Factual background and analysis: Entitlement to service connection for a chronic sinus disability, to include sinusitis and rhinitis. The Veteran's service treatment records reflect, in pertinent part, that he was treated on several occasions for sinus pressure pain with associated nasal discharge. In a February 2009 lay witness statement from E.P., he reported that he was a fellow serviceman who personally knew the Veteran and served with him in 1973 - 1974, and 1987 - 1989. During service, he observed that the Veteran had problems performing his duties because of interference to his health from recurring sinus problems. In an August 2009 report, a VA physician stated that he reviewed the Veteran's pertinent clinical history and examined him. The examiner's opinion was that the Veteran's sinus diagnoses were allergic rhinitis and sinusitis that were due to, or the result of active military service, based on his history of treatment for these conditions during active duty, his current ongoing treatment and diagnosis for the same, and the examining physician's own clinical experience and expertise. The Veteran's private medical consultant, Dr. Bash, expressed nexus opinions in August 2005 and April 2011 that were congruent and in general concurrence with the VA examiner's August 2009 opinion. Thusly, in the absence of any medical evidence presenting an opposite opinion that probatively outweighs the favorable private and VA opinions discussed above, the Board will concede that the Veteran's current diagnoses of allergic rhinitis and sinusitis had their onset during active duty. This factual conclusion is supported by the preponderance of the objective medical evidence pertinent to this claim. (c.) Factual background and analysis: Entitlement to service connection for a chronic cervical spine disability with neck muscle spasm; a bilateral AC joint disability with muscle spasm of the shoulders; a chronic lumbosacral spine disability; and arthritis of the left knee. The Veteran's service treatment records show that he was involved in a serious motor vehicle accident in 1983 while in the line of duty, in which he sustained a closed head injury with concussion (without loss of consciousness), muscle pain of his neck and trapezius, left knee pain and swelling due to a spraining injury, and cervical strain due to a whiplash injury. Post-service orthopedic and neurological records from private medical care sources show ongoing treatment for complaints of neck pain, low back pain, left knee pain due to osteoarthritis, and bilateral shoulder pain, with limitation of motion and general functional impairment due to diagnoses of spondylosis, osteoarthritis, and degenerative joint disease of the cervical spine, bilateral AC joint osteoarthritis, and arthritic spurring of the L4-L5 vertebrae with degenerative changes, with muscle spasm associated with each of the foregoing diagnoses. As relevant, a nexus opinion presented by a VA physician following medical examination of the Veteran in January 2006 and review of his pertinent clinical history drew a direct link between the traumatic neck injuries sustained in service from the documented 1983 motor vehicle accident with his current diagnosis of multilevel cervical spondylosis, osteoarthritis, and degenerative joint disease with associated neck muscle spasm. In medical opinions predicated on examination of the Veteran and clinical review of his history, Dr. Bash also expressed concurring nexus opinions in August 2005 and April 2010. Similarly, Dr. Bash presented nexus opinions in April 2010 and April 2011 that it was at least as likely as not that the Veteran's current orthopedic disabilities of his bilateral shoulders and low back (diagnosed as bilateral AC joint osteoarthritis with muscle spasm and arthritic spurring of the L4-L5 vertebrae with degenerative changes and muscle spasm) and his left knee (diagnosed as osteoarthritis of the left knee) were the residuals of traumatic injuries sustained in the 1983 motor vehicle accident that occurred in military service. Although the service treatment records do not objectively reflect onset of a chronic disability of the Veteran's left knee, shoulders, AC joints, or lumbosacral spine, Dr. Bash offered as his supportive rationale that, in essence, given the severity of the in-service motor vehicle accident and the Veteran's reported history of onset of chronic left knee pain and crepitus, bilateral shoulder pain and low back pain since military service, the current orthopedic diagnoses and clinical findings associated with his left knee, AC joints, shoulders, and lumbosacral spine, and their delayed onset of manifest symptoms, are not inconsistent with residuals of traumatic injuries to these joints that would be sustained in the type of motor vehicle accident documented in the Veteran's history. Dr. Bash further stated that the severity of the Veteran's left knee crepitus was out of proportion to his age and was consistent with residuals of an antecedent trauma such as the motor vehicle accident in service. Thusly, in the absence of any medical evidence presenting an opposite opinion that probatively outweighs the foregoing favorable private and VA opinions, the Board will concede that the Veteran's current diagnoses of osteoarthritis of the left knee, spondylosis, osteoarthritis, and degenerative joint disease of the cervical spine, bilateral AC joint osteoarthritis, and arthritic spurring of the L4-L5 vertebrae with degenerative changes, had their onset during active duty. This factual conclusion is supported by the preponderance of the objective medical evidence pertinent to these claims. (d.) Entitlement to service connection for hypertension. The Veteran's current medical records, including a VA examination conducted in January 2006, establish that he has a present diagnosis of hypertension treated with medication, with systolic pressure readings as high as 158 and diastolic pressure readings as high as 100 obtained in January 2006. In this regard, sustained systolic blood pressure readings of 140 or above and diastolic blood pressure readings of 90 or above are generally regarded by current medical science to represent essential hypertension. His service records show several incidents in which elevated systolic and diastolic blood pressure readings were obtained. As examples, in February 1981, his blood pressure (systolic/diastolic in millimeters of mercury) measured 140/90; in March 1982 it was 142/90; in August 1983 it was 126/90 and 134/90; in February 1987 it was 148/100; in October 1987 it was 148/98; and on service separation examination in March 1989 it was 130/90, accompanied by a diagnosis of rule out hypertension. In an August 2005 private medical statement, Dr. Craig N. Bash reported that he reviewed the Veteran's claims file, noted that there were several notations of elevated blood pressure readings shown in his service treatment records, and gave a rather broadly worded and general opinion that the Veteran's hypertension had is onset during his period of active duty. Notwithstanding the absence of a detailed rationale to support Dr. Bash's nexus opinion, the Board finds that this opinion, when viewed in the context of the Veteran's service treatment records that show repeated findings of elevated blood pressure readings during active duty, including an elevated reading noted on separation from service that elicited the examiner to diagnose rule out hypertension, demonstrate that the clinical evidence is in relative equipoise with regard to the issue of whether or not hypertension had its onset during military service. Therefore, resolving any doubt in the Veteran's favor, the Board concludes that service connection for hypertension is warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The appeal in this regard is thus granted. (e.) Entitlement to service connection for a scar of the left side of the neck. The Board notes at the outset that, in accordance with the Veterans Claims Assistance Act of 2000 (VCAA), VA has an obligation to notify claimants what information or evidence is needed in order to substantiate a claim, as well as a duty to assist claimants by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A and 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2010); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). With respect to the claim for service connection claim for a scar of the left side of the neck, generally, the notice requirements of a service connection claim have five elements: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must also: (1) inform the claimant about the information and evidence necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; (3) inform the claimant about the information and evidence the claimant is expected to provide; and (4) request that the claimant provide any evidence in his possession that pertains to the claim. See 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b); Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). Section 3.159(b), 38 C.F.R., was revised and the requirement that VA request that the claimant provide any evidence in his possession that pertains to the claim was removed from the regulation. The service connection claim decided herein stems from the Veteran's application that was filed in August 2004. A VCAA notice letter addressing the applicability of the VCAA to this issue and of VA's obligations to the Veteran in developing the claim was dispatched to the Veteran afterwards in August 2004, which satisfied the above-described mandates. There is no timing of notice error as the letter preceded the initial adjudication of the claim. Although the August 2004 letter did not inform the Veteran of how VA calculates degree of disability and assigns an effective date for the disability, as prescribed in Dingess v. Nicholson, 19 Vet. App. 473 (2006), to the extent that this constitutes a deficit in notice, the Board finds that there is no prejudicial error as this appellate decision is denying the claim being sought on appeal, and therefore the question of ratings and effective dates for an award of VA compensation with respect to this particular claim is rendered moot. Furthermore, neither the Veteran nor his representative have made any assertion that there has been any defect in the timing or content of the VCAA notification letters associated with this specific claim. VA also has a duty to assist the Veteran in obtaining evidence necessary to substantiate the claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the Veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). VA informed the Veteran of its duty to assist in obtaining records and supportive evidence. In this regard, the Board observes that the Veteran's service treatment records have been obtained. Although the records are not entirely complete, as they include only those records dated from 1980 through the end of active duty, including the Veteran's separation examination of March 1989, they are sufficient to adjudicate the claim at issue as they include a detailed examination of the Veteran's skin and neck on separation from active duty and thusly would provide sufficiently definitive and outcome-determinative evidence of whether or not the claimed disabling condition had its onset in service. The Veteran was also afforded a VA examination in January 2006, which addressed his neck scars and noted the Veteran's alleged history regarding their service onset. Thus, the present state of development of the evidence of record is deemed to be adequate for adjudication purposes for the matter at issue. Based on the foregoing, the Board finds that the VA fulfilled its VCAA duties to notify and to assist the Veteran in the evidentiary development of his claim for service connection for neck scars decided herein, and thus no additional assistance or notification is required in this regard. The Veteran has suffered no prejudice that would warrant a remand, and his procedural rights have not been abridged. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board will therefore proceed with the adjudication of this appeal. In his oral testimony before the Board in March 2011, and in written statements presented in support of his claim, the Veteran alleged that he was physically assaulted during active duty while stationed in West Germany and sustained a laceration injury to the left side of his neck that required closure with sutures. Noting this historical account, the Veteran was examined by VA in January 2006 and observed to have a 15-centimeter long scar going from back to front on the left side of his neck that was well-healed and objectively asymptomatic. As a point of clarification, the Veteran specifically stated at his March 2011 hearing that his scar on his left neck was not a residual of the surgery he received for excision of his service-connected vocal cord polyp, as that procedure was performed through his opened mouth and throat and not through external incision of his neck. The Veteran's available service treatment records for the period from 1980 - 1989 show no treatment or notation by history of the Veteran's alleged laceration injury to his neck or any residual scar. Significantly, on separation examination in March 1989, the Veteran's skin and neck were examined and no scars of the neck were detected, nor any notation by way of history that he sustained a laceration injury to this area from being physically assaulted. The Board has considered the foregoing evidence and finds that it is not plausible that such a long and conspicuous neck scar as the one described on VA examination in January 2006 could somehow escape notice and detection on service separation examination in March 1989. The March 1989 separation examination essentially found the Veteran's neck and skin to be normal and no such scar was observed. As such, the Board finds that the objective evidence contradicts the Veteran's account of having sustained a laceration injury with residual scarring of the left side of his neck as a result of being the victim of a physical assault during active duty. The Board thusly finds that the Veteran's historical account in this regard is not credible for purposes of establishing a nexus between his claimed neck scar and military service. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Absent any objective or credible evidence to establish a link between the scar on the Veteran's neck and his period of active duty, his claim for service connection for a scar of the left side of his neck must be denied. Because the evidence in this case is not approximately balanced with respect to the merits of this claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for internal and external hemorrhoids, status post multiple hemorrhoidectomies (and their associated disabling residuals, to include impaired sphincter control and intestinal fistula with fecal discharge), and diverticular disease is granted. Service connection for allergic rhinitis and sinusitis is granted. Service connection for spondylosis, osteoarthritis, and degenerative joint disease of the cervical spine is granted. Service connection for bilateral AC joint osteoarthritis is granted. Service connection for arthritic spurring of the L4-L5 vertebrae with degenerative changes is granted. Service connection for hypertension is granted. Service connection for osteoarthritis of the left knee is granted. Service connection for a scar of the left side of the neck is denied. REMAND With regard to the issue of entitlement to an initial evaluation above 10 percent for chronic laryngitis, status post vocal cord polyp, from February 15, 2006, the Veteran has contended at his March 2011 hearing and in written statements in support of his claim that he continues to experience severe hoarseness of his voice, even after the disabling vocal cord polyp was surgically excised from his larynx in February 2006. Under the criteria contained in 38 C.F.R. § 4.97, Diagnostic Code 6516, a 30 percent evaluation is assigned for chronic laryngitis manifested by hoarseness, with thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. Although clinical findings obtained on VA examinations of the Veteran's throat, which were conducted in September 2008 and August 2009, indicate that there was no evident recurrence of his vocal cord polyp, the examination reports do not present specific findings as to whether or not there was thickening or nodules of the Veteran's vocal cords, or submucous infiltration. As an objective finding of such pathology would support the assignment of a 30 percent evaluation for his service-connected laryngeal disability, and as it cannot be determined from the current examinations whether or not these conditions are present, a remand is warranted so that the Veteran can be provided with a new VA medical examination that will address and rectify this evidentiary deficit in the current record. [When VA undertakes the effort to provide a medical examination, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). A medical opinion is considered adequate when it is based on consideration of an appellant's prior medical history and examinations and describes the disability in sufficient detail so that the Board's evaluation of the claimed disability is a fully informed one. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007).] Accordingly, in view of the foregoing discussion, the case is REMANDED to the RO via the AMC for the following action: 1. The evidentiary record with regard to examinations and treatment of the Veteran's larynx is current up to August 2009. To ensure that the relevant evidence is as current as possible, after obtaining from the Veteran a report of all sources of treatment (both private and VA) relating to his larynx since August 2009, as well as all necessary authorizations for their release, the RO should obtain these identified records and associate them with the Veteran's claims file. All actions to obtain the aforementioned requested records should be documented fully in the claims files. 2. After the above development has been undertaken, the RO should provide the Veteran with the appropriate medical examination to determine the current severity of his service-connected chronic laryngitis, status post vocal cord polyp. All tests deemed appropriate by the examiner should be performed. The Veteran's claims files and his relevant clinical history should be made available for the examiner's review in connection with the examination. In this regard, the examiner's conclusions regarding the current severity of the Veteran's chronic laryngitis, status post vocal cord polyp, should be made in the context of the clinical records associated with the claims files and the VA otolaryngological treatment records dated since the most recent compensation examination in August 2009. The examiner should note in his/her report that the Veteran's claims file has been reviewed. Following the examination, the examiner should present specific clinical findings in the examination report with regard to the following: (a.) Is the Veteran's chronic laryngitis, status post vocal cord polyp, manifested (best approximated) by hoarseness, with thickening or nodules of the vocal cords, polyps, submucous infiltration, or pre-malignant changes on biopsy? (b.) Is the Veteran's chronic laryngitis, status post vocal cord polyp, manifested (best approximated) by hoarseness, with inflammation of the vocal cords or mucous membrane? The examiner should provide a complete rationale for any opinion provided. If he/she is unable to provide an opinion without resorting to speculation or conjecture, he/she should so state in his/her discussion and explain why. 3. Afterwards, the RO should review the claims files to ensure that the aforementioned development and remand instructions have been fully and properly executed. Any noncompliance found should be rectified with the appropriate development. 4. Thereafter, the RO should readjudicate the Veteran's claim of entitlement to an initial evaluation greater than 10 percent for chronic laryngitis, status post vocal cord polyp, from February 15, 2006. Such readjudication should take into account whether "staged" ratings are appropriate. Fenderson v. West, 12 Vet. App. 119 (1999). If the maximum benefit sought on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case which takes into account all evidence received by VA since the June 2010 statement of the case and afforded a reasonable opportunity to respond before the record is returned to the Board for further appellate review, if appropriate. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs