Citation Nr: 1211488 Decision Date: 03/30/12 Archive Date: 04/05/12 DOCKET NO. 07-12 515 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for epididymitis. 2. Entitlement to service connection for incontinence, to include secondary to epididymitis. 3. Entitlement to service connection for a prostate disorder, to include secondary to epididymitis. 4. Entitlement to service connection for a kidney disorder to include secondary to epididymitis. 5. Entitlement to service connection for hypertension. 6. Entitlement to service connection for bilateral nuclear sclerotic and anterior subcapsular cataracts (claimed as posterior subcapsular cataracts), to include a result of ionizing radiation exposure. 7. Entitlement to a compensable rating for bilateral hearing loss. REPRESENTATION Appellant represented by: Virginia Department of Veterans Services ATTORNEY FOR THE BOARD M. H. Stubbs, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1954 to January 1959, and from April 1959 to April 1965. He has additional Army National Guard service. These matters come before the Board of Veterans' Appeals (Board) on appeal from December 2005 (hearing loss), September 2006 (cataracts), and July 2008 (remaining) rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issues of entitlement to service connection for nuclear sclerotic and anterior subcapsular cataracts, a kidney disorder, a prostate disorder, and incontinence are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran was diagnosed with epididymitis in service; he has credibly asserted continuity of symptomatology since service, and the claims file contains a medical nexus between a current diagnosis of epididymitis and service. 2. The Veteran has not been diagnosed with hypertension. 3. The Veteran's bilateral hearing loss is manifest by no worse than Roman Numeral Level II hearing in the right ear and Roman Numeral Level I hearing in the left ear during the period on appeal. An exceptional pattern of hearing impairment has not been manifested. CONCLUSION OF LAW 1. Resolving reasonable doubt in the Veteran's favor, epididymitis was incurred in-service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107(b) (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102 , 3.159, 3.303 (2011). 2. Hypertension was not incurred or aggravated inservice, and it may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102 , 3.159, 3.303, 3.307, 3.309 (2011). 3. The requirements for a compensable evaluation for bilateral hearing loss are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.85, 4.86, Diagnostic Code 6100 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The requirements of the VCAA, Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100 , 5102, 5103, 5103A, 5106, 5107, and 5126), have been met. There is no issue as to providing an appropriate application form or completeness of the application. Prior to the rating decisions appealed, VA notified the Veteran in August 2005, February 2006, December 2007, and June 2008 of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, and notice of how disability ratings and effective dates are assigned. The claims were readjudicated in a February 2009 statement of the case and a January 2012 supplemental statements of the case. Thus, any timing-of-notice error was cured and rendered harmless. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). Thus, VA has complied with the VCAA notice requirements. See 38 C.F.R. § 3.159(b). VA has also fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. See 38 C.F.R. § 3.159(c). An examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)(4). In McLendon v. Nicholson, 20 Vet. App. 79 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the third prong, which requires an indication that the claimant's disability or symptoms 'may be' associated with the established event, is a low threshold. Simply stated, the standards of McLendon are not met in this case regarding the claim of entitlement to service connection for hypertension, as there is no evidence of a current disability. In sum, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. Hence, the Board may address the merits of the appeal. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by an appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Service Connection Service connection may be granted for any current disability for which it is shown was caused by a disease or injury incurred or aggravated during service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) competent evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) competent evidence of a nexus between the claimed in-service disease or injury and the present disability. See generally Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The absence of any one element will result in the denial of service connection. Coburn v. Nicholson, 19 Vet. App. 427 (2006). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and/or third element is through a demonstration of continuity of symptomatology. See 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. Id. at 495. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Epididymitis In September 2007, the Veteran filed a claim of entitlement to service connection for epididymitis, claiming his condition began in 1960 and had been ongoing since its first manifestation in service. Service treatment records include a January 1954 enlistment examination, which found the Veteran's genitourinary system to be normal on clinical evaluation. In November 1960, he complained of pain in his right testicle, and by December 1960 a firm nodule was felt at the posterior-superior pole of the right testicle. He was assessed with chronic epididymitis. No abnormalities were noted on his March 1965 discharge clinical evaluation. Private treatment records from Dr. L. include a September 2007 ultrasound viewing of the scrotum which revealed bilateral epididymal head cysts and calcifications in the right epididymal tail. Dr. L. additionally diagnosed the Veteran with a spermatocele in December 2007. The Veteran and his wife provided statements containing credible evidence of continuity of symptomatology. In September 2007, the Veteran described the 1960 onset of acute right testicle pain, followed by ongoing treatment with heat and elevation. When his disorder did not change with 10 days of treatment in he was told to use scrotal support and cease heavy lifting. He reported that following service his epididymitis continued to be an ongoing problem. He described discomfort on a daily basis with flare-ups of pain with activity. He also described continued use of pain medication and scrotal support from service through to the present. In a June 2008 statement, his wife described how his epididymitis caused so much discomfort and pain that it occasionally limited his daily activities. In January 2008, Dr. C.N.B. provided an opinion linking the Veteran's current epididymitis to his in-service right testicle pain and epididymitis. Dr. C.N.B. noted the Veteran entered service fit for duty, but developed scrotal pain in November 1960, and has reported a history of testicular pain and urinary symptoms since service. Based upon his lay assertions and a review of his records, Dr. C.N.B. found that it was likely the Veteran had suffered from chronic epididymitis, orchitis, prostatitis and cystitis over the years. He opined that the Veteran's current epididymitis "either began during service and/or are secondary to the chronic infectious process that began during service." A medical treatise on the organisms that can cause epididymitis is quoted as support for the physician's positive opinion. Based on evidence of epididymitis in service, credible evidence of ongoing symptoms of epididymitis from service to the present, and a positive nexus opinion provided by a private physician, the Board will resolve reasonable doubt in the appellant's favor and grant entitlement to service connection for epididymitis. Hypertension For VA rating purposes, "hypertension" means that diastolic blood pressure is predominately 90 mm. or greater; "isolated systolic hypertension" means that the systolic blood pressure is predominately 160 mm. or greater with a diastolic blood pressure of less than 90 mm. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. Id. Certain chronic disabilities, such as hypertension, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Service treatment records do not include treatment for, complaints of, or a diagnosis of hypertension. The Veteran's blood pressure at his January 1954 entrance examination was 118/70. In September 1960 the appellant's blood pressure was 112/70. His blood pressure at a March 1965 discharge examination was 122/66. VA and non-VA treatment records in the claims file do not include a diagnosis of hypertension. There are limited blood pressure readings contained in the available records. On September 3, 2004, the Veteran underwent a laparoscopic appendectomy. Pre-procedure his blood pressure was 134/59 and 130/67. His blood pressure readings subsequent to surgery were 142/74 (September 5), 137/68 (September 6), and 150/77 (September 7). Following low urine output on September 8, 2004 his blood pressure reading was 151/95; however, following treatment his blood pressure lowered to 149/75. The following day his blood pressure was 123/63. Despite being in recovery from surgery, the Veteran's blood pressure remained below the definition of "hypertension" for VA purposes except for one reading. This one high reading was not confirmed by readings taken two or more times on at least three different days. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. Additionally, during this hospitalization there the Veteran was not diagnosed with hypertension or noted to have high blood pressure. In January 2008, Dr. C.N.B. opined that if the Veteran currently had high blood pressure he should be service-connected for hypertension because he had one instance of a high diastolic (90mm) pressure in service. [N.B. As noted above, the actual finding was 112/70, not 112/90 was reported by Dr. C.N.B.] Dr. C.N.B.'s letter did not indicate that he examined the Veteran and did not include a blood pressure reading for the appellant or a diagnosis of hypertension. While the Veteran has appealed the claim of entitlement to service connection for hypertension which was initiated by Dr. C.N.B.'s January 2008 letter, he has not made any statements outlining his theory of entitlement. While Dr. C.N.B. alluded to a single instance of high diastolic pressure in service, he did not diagnose the Veteran with hypertension, and thus his statement does not provide a basis for allowance of the claim. The Veteran was not diagnosed with hypertension during service, and has not been diagnosed with hypertension since service. The claims file contains a single elevated blood pressure reading following complications from a 2004 appendectomy. A blood pressure reading taken later in the same day, and a blood pressure reading taken the following day were both normal. The Veteran was not diagnosed with hypertension during his hospitalization. Where, as here, medical evidence does not establish that the Veteran has the disability for which service connection is sought, there can be no valid claim for service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). Additionally, as the claim for entitlement to service connection was not initiated until 2008, the instance of high blood pressure in 2004 was not during the pendency of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Accordingly, entitlement to service connection for hypertension must be denied, because the first essential criterion for a grant of service connection-evidence of a current disability upon which to predicate a grant of service connection-has not been met. Increased Rating-Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In general, 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. Evaluations of defective hearing range from non-compensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with the average hearing threshold level measured by puretone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). To evaluate the degree of disability from service-connected defective hearing, the schedule establishes 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. § 4.85, Tables VI and VII, Diagnostic Code 6100. Disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenman v. Principi, 3 Vet. App. 345 (1992). An exceptional pattern of hearing impairment occurs when the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. In that situation, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. 38 C.F.R. § 4.86. Further, when the average puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. Id. Factual Background and Analysis In July 2005, the Veteran filed a claim of entitlement to a compensable rating for bilateral hearing loss, stating that his hearing loss affected his ability to use communication equipment necessary for his employment. A coworker provided a lay statement that their employment involved the use of two way radios, and that the Veteran often had to have people repeat themselves. The Veteran's wife provided a statement that the Veteran had suffered from hearing loss in his right ear for more than 20 years, but that in the past 7 to 8 years his hearing loss began to affect his personal and professional life. She wrote that he had difficulty hearing the telephone ring, hearing people talk over the telephone, and hearing the doorbell. She also noted that he would turn his left ear towards people to be able to understand them during conversations. In September 2005, the Veteran was afforded a fee-basis VA audio examination. He reported difficulty understanding people on the telephone and on two way radios at work. He used bilateral hearing aids for the past four years. Auricle examination and external ear examination was normal bilaterally. Audiological examination yielded right ear pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz of 20, 35, 55, and 70 decibels, respectively, for an average of 45 decibels. Pure tone thresholds measured in the left ear at 1000, 2000, 3000, and 4000 Hertz were 20, 25, 40, and 50 decibels, respectively, with an average of 34 decibels. Speech discrimination scores were reported as 84 percent for the right ear and 92 percent for the left ear. Private treatment records form Dr. B.D.D. from February 2006 included complaints occasional imbalance, and difficulty hearing even with the use of hearing aids. Although pure tone thresholds were not provided, Dr. B.D.D. indicated the Veteran suffered from moderate sensorineural hearing loss at high frequencies bilaterally, with "excellent speech discrimination" bilaterally. In March 2007, the Veteran provided a copy of an air conduction examination from a VA Medical Center. Audiological examination yielded right ear pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz of 30, 30, 55, and 60 decibels, respectively, for an average of 43.75 decibels. Pure tone thresholds measured in the left ear at 1000, 2000, 3000, and 4000 Hertz were 25, 35, 40, and 65 decibels, respectively, with an average of 41.25 decibels. Speech discrimination scores were reported as 96 percent in the right ear, and 100 percent in the left ear. In December 2011, the Veteran was afforded an additional fee-basis VA audio examination. Audiological examination yielded right ear pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz of 15, 30, 55, and 65 decibels, respectively, for an average of 41.25 decibels. Pure tone thresholds measured in the left ear at 1000, 2000, 3000, and 4000 Hertz were 20, 20, 40, and 55 decibels, respectively, with an average of 33.75 decibels. Speech discrimination scores were reported as 94 percent for the right ear and 96 percent for the left ear. The examiner opined that the Veteran's hearing loss should not affect his ability to work. The objective findings show that at no time on appeal has the Veteran's hearing loss been manifested with an exceptional pattern of hearing impairment as defined by 38 C.F.R. § 4.86. At the worst, the right ear manifested a Level II hearing loss, and the left ear manifested a Level I hearing loss under Table VI. 38 C.F.R. § 4.85, Diagnostic Code 6100. Under Table VII, one ear manifesting in Level II impairment and the other ear manifesting in Level I impairment warrant a noncompensable rating. Id. The Board acknowledges that in Martinak v. Nicholson, 21 Vet. App. 447 (2007), the Court held that in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. In this case, the VA examiner in 2006 noted that the Veteran had difficulty communicating via telephone or two way radio. The 2011 examiner indicated the Veteran's hearing loss did not impact his ordinary conditions of daily life or ability to work, but noted he should be fitted for hearing aids. There is no basis, however, for assignment of a compensable rating for the Veteran's service-connected bilateral hearing loss. While the Veteran's statements regarding increased difficulty hearing and communicating over the past eight years are deemed credible, disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). The Board has considered the propriety of a referral for consideration of higher rating on an extraschedular basis under 38 C.F.R. § 3.321(b)(1). The Board, however, finds that the rating criteria describe the Veteran's hearing loss and the levels of the severity of the disability. His disability is no different than other veterans who are rated under the schedule for a bilateral hearing loss. Hence, his hearing loss disability is not exceptional. See Thun v. Peake, 22 Vet. App. 111 (2008). In the absence of an exceptional disability picture, referral for extraschedular consideration is not allowed. See 38 C.F.R. § 3.321(b)(1). The Board also notes that evidence in the claims file notes that the Veteran is employed. Hence, there is no need to address the appellant's entitlement to a total disability evaluation based on individual unemployability. ORDER Entitlement to service connection for epididymitis is granted. Entitlement to service connection for hypertension is denied. Entitlement to a compensable rating for bilateral hearing loss is denied. REMAND Prostate, Kidney, and Incontinence The Veteran claims entitlement to service connection for a prostate disorder, kidney disorder and incontinence secondary to epididymitis. In a November 2008 letter, Dr. L. indicated the Veteran has chronic prostatitis that was diagnosed in 1960 during the appellant's military service. Dr. C.N.B., in his January 2008 discussion, indicated that it was likely the Veteran has a chronic kidney infection, and "due to the extent of his [genitourinary] infections his bladder voiding system is dysfunctional causing his incontinence." Dr. C.N.B. indicated the Veteran was likely incontinent due to "cystitis (bladder infections) or prostatitis or infection induced urinary bladder sphincter dysfunction." It does not appear from his discussion, however, that Dr. C.N.B. actually examined the Veteran. On remand, the Veteran must be afforded a VA examination in connection with these secondary claims. McLendon. Should service connection be granted for any of these disorders, the RO is respectfully reminded that pyramiding, i.e., the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, must be avoided. 38 C.F.R. § 4.14. In cases where the record reflects that the appellant has multiple problems due to service- connected disability, it is possible for an appellant to have "separate and distinct manifestations" permitting separate ratings. Esteban v. Brown, 6 Vet. App. 259, 261 (1994). The critical element is that none of the symptomatology for any of the conditions is duplicative or overlapping with the symptomatology of the other conditions. Id. Cataracts The Veteran claims entitlement to service connection for nuclear sclerotic and anterior subcapsular cataracts due to exposure to ionizing radiation during service. The Veteran's service treatment records reveal he was exposed to ionizing radiation during service as a dental technician. Service treatment records contained in the claims file include some DD 1141 radiation exposure dose measurements. The Veteran contends that the measurements contained in the claims file are not a complete record of his exposure. On remand, the RO/AMC should ensure that all available DD 1141 and other dose measurements are obtained and included in the claims file. In June 2006, the Veteran was afforded a fee-basis VA eye examination. The examiner opined the appellant's cataracts were less likely than not a result of his service-related activities; however, he concluded his opinion by noting "the Veteran's [ionizing radiation] dose was likely to be lower than the" causative values cited by the examiner. (Emphasis added.) The examiner did not provide a rationale for his belief the Veteran's radiation doses would be lower than the causative values he cited, and the VA has not provided ionizing radiation dose estimates for the Veteran. In November 2006, Dr. C.N.B. provided ionizing radiation dose estimates for the Veteran's service as a dental technician in the late 50s/early 60s. He provided two estimates, one based upon worst-case estimations of the number of x-rays he may have provided in a year multiplied by 9 years, and another based upon the average dose per year for a dental worker multiplied by 9 years. Dr. C.N.B. noted that the Veteran's exposure to ionizing radiation as a dental technician would have been higher during the 1960s than with current technology and methodologies. Significantly, Dr. C.N.B. did not provide evidence explaining his assumption that the appellant did as many as 2000+ dental x-ray examinations/year. Dr. C.N.B. provided a positive nexus opinion between the Veteran's current cataracts and his in-service exposure to ionizing radiation. While posterior subcapsular cataracts is listed as a "radiogenic disease" under 38 C.F.R. § 3.311(a)(4)(b)(2), nuclear sclerotic and anterior subcapsular cataracts are not. However, 38 C.F.R § 3.311(b)(4) shows that diseases not included in the list of radiogenic diseases in the regulation shall developed in the same way that radiogenic diseases are developed if the claimant cited or submitted competent scientific or medical evidence that the claimed condition is a radiogenic disease. See 38 C.F.R. § 3.311. Here, Dr. C.N.B. has indicated that the Veteran's cataracts may be radiogenic diseases, and as such additional development is required. A review of the claims file shows that the Veteran's available DD 1141s were not forwarded to the Under Secretary for Health for preparation of a dose estimate. According to 38 C.F.R. § 3.311(a) a request must be made for any available records concerning the Veteran's exposure to radiation. These records normally include but may not be limited to a veteran's Record of Occupational Exposure to Ionizing Radiation (DD Form 1141), if maintained, service medical records, and other records which may contain information pertaining to the veteran's radiation dose in service. All such records will be forwarded to the Under Secretary for Health, who will be responsible for preparation of a dose estimate, to the extent feasible, based on available methodologies. 38 C.F.R. § 3.311(a)(2)(iii). This regulation indicates that the Under Secretary for Benefits will make a determination as to whether it is at least as likely as not that any of the Veteran's claimed disability resulted from exposure to radiation in service. 38 C.F.R. § 3.311(c)(i). Also, 38 C.F.R. § 3.311(a)(3) notes that, when necessary to reconcile a material difference between an estimate of dose from a credible source, submitted by or on behalf of a claimant, and dose data derived from official military records, the estimates and supporting documentation shall be referred to an independent expert, selected by the Director of the national institutes of Health, who shall prepare a separate radiation dose estimate for consideration in adjudication of the claim. The RO/AMC should ensure that all other necessary development under 38 C.F.R. § 3.311 is carried out prior to readjudication of the claim. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). Expedited handling is requested.) 1. The RO/AMC must take appropriate action to secure any and all pertinent records which have been identified but not previously secured for inclusion in the claims file, to specifically include any outstanding DD Forms 1141 or other service records which may include radiation information. All attempts to secure this evidence must be documented in the claims file. If the AMC/RO cannot locate such records, the AMC/RO must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The AMC/RO must then: (a) notify the Veteran, his representative and his legal custodian of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claim. The Veteran and his legal custodian must then be given an opportunity to respond. 2. Thereafter, forward the claims file to the Under Secretary for Health for preparation of a dose estimate, to the extent feasible, based on all appropriate and available methodologies. 3. After securing a dose estimate, determine whether referral to an independent expert under 38 C.F.R. § 3.311(a)(3) is necessary. Before its adjudication, refer the claim to the Under Secretary of Benefits for further consideration in accordance with 38 C.F.R. § 3.311(c). See 38 C.F.R. § 3.311(b)(1). 4. The Veteran must be afforded a genitourinary examination, to be conducted by a physician, to determine the nature and etiology of any diagnosed kidney disorder, prostate disorder, and any disorder manifested by incontinence. All indicated tests must be accomplished. Symptoms of each diagnosed disorder should be clearly listed. The claims folder, all Virtual VA records, and a copy of this remand, must be provided to and reviewed by each examiner as part of the examination. The examiner must specify in the report that the claims file and Virtual VA records have been reviewed. The examiner must specify the dates encompassed by the Virtual VA records. Thereafter, the examiner must opine it is at least as likely as not, i.e., is there a 50/50 chance or greater, that any diagnosed kidney, prostate or other disorder manifested by incontinence is related to active service. The examiner must further opine whether it is at least as likely as not, i.e., is there a 50/50 chance or greater, that any diagnosed kidney, prostate or other disorder manifested by incontinence is a result of or aggravated by epididymitis. The examiner must comment on Dr. C.N.B.'s January 2008 discussion and opinion. A complete rationale for any opinion offered must be provided. 5. The AMC/RO must ensure that all medical examination reports and opinion reports comply with this remand and the questions presented in the request. The AMC/RO must ensure that the examiners documented their consideration of all records contained in Virtual VA. If any report is insufficient, it must be returned to the examiner for necessary corrective action, as appropriate. 6. The Veteran must be given adequate notice of the date and place of any ordered examination. The Veteran is to be advised that failure to report for a scheduled VA examination without good cause shown may have adverse effects on his claim. 7. After the development requested above has been completed to the extent possible, the AMC/RO must again review the record. If any benefit sought on appeal remains denied, the appellant and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, the case should be returned to the Board, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs