Citation Nr: 1301668 Decision Date: 01/15/13 Archive Date: 01/23/13 DOCKET NO. 07-28 069A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for bilateral hearing loss disability. 2. Entitlement to service connection for recurrent tinnitus. 3. Entitlement to service connection for cardiac arrhythmia to include as secondary to a service-connected disability. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from October 1952 to September 1954. These matters come before the Board of Veterans' Appeals (Board) from a May 2005 (bilateral hearing loss disability and tinnitus) rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Cleveland, Ohio, and a December 2006 (cardiac arrhythmia) rating decision of VARO in Chicago, Illinois. These matters were previously before the Board in August 2010 and May 2011 and were remanded for further development. They have now returned to the Board for further appellate consideration. As discussed in further detail below, the Board finds that the RO substantially complied with the mandates of its remand with regard to the issues of entitlement to service connection for bilateral hearing loss disability and entitlement to service connection for tinnitus, and will proceed to adjudicate the appeal. See Dyment v. West, 13 Vet. App. 141 (1999) (noting that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In its May 2011 remand, the Board remanded the issues of entitlement to service connection for chronic hypertension to include as secondary to a service-connected psychiatric disability, and entitlement to service connection for coronary artery disease (CAD) to include as secondary to a service-connected psychiatric disability. In an October 2012 rating decision, the RO granted service connection for both disabilities; thus, those issues are no longer for appellate consideration. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of entitlement to service connection for cardiac arrhythmia, to include as secondary to a service-connected disability 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. FINDINGS OF FACT 1. There has been no demonstration by competent medical evidence of record, that the Veteran has bilateral hearing loss disability for VA purposes. 2. A lay person, to include the Veteran, is not competent to diagnose hearing loss disability for VA purposes. 3. The Veteran is less than credible with regard to the onset of tinnitus. 4. There has been no demonstration by competent medical, nor competent and credible lay, evidence of record, that the Veteran has tinnitus causally related to, or aggravated by, active service. CONCLUSIONS OF LAW 1. Bilateral hearing loss disability was not incurred in, or aggravated by, active service, nor may it be presumed (as an organic disease of the nervous system), to have been so incurred or aggravated. 38 U.S.C.A. §§ 1101, 1110, 1137, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2012). 2. Tinnitus was not incurred in, or aggravated by, active service, nor may it be presumed (as an organic disease of the nervous system), to have been so incurred or aggravated. 38 U.S.C.A. §§ 1101, 1110, 1137, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Duty to Notify Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). On March 3, 2006, the United States Court of Appeals for Veterans Claims (Court) issued its decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Court in Dingess/Hartman held that the VCAA notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim. As previously defined by the courts, those five elements include: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Upon receipt of an application for "service connection," therefore, VA is required to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, it will assist in substantiating or that is necessary to substantiate the elements of the claim as reasonably contemplated by the application. This includes notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In VA correspondence to the Veteran in October 2004, VA informed him of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. In September 2010 correspondence, VA informed the Veteran of the criteria for assignment of a disability rating and effective date in the event of award of service connection. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that compliance with 38 U.S.C.A. § 5103 required that VCAA notice be provided prior to an initial unfavorable agency of original jurisdiction decision. Because the VCAA notice was not completed prior to the initial AOJ adjudication denying the claims, the timing of the notice does not comply with the express requirements of the law as found by the Court in Pelegrini. Here, the Board finds that any defect with respect to the timing of the VCAA notice was harmless error. Although complete notice was provided to the appellant after the initial adjudication, the claims were readjudicated thereafter, and the appellant therefore, has not been prejudiced. The content of the notice fully complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b), and Dingess/Hartman. The Veteran has been provided with every opportunity to submit evidence and argument in support of his claim, and to respond to VA notices. The VCAA requires that the duty to notify is satisfied, and that claimants are given the opportunity to submit information and evidence in support of their claims. Once this has been accomplished, all due process concerns have been satisfied. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996). The Board finds the VCAA notice requirements have been met in this case. Duty to assist With regard to the duty to assist, the claim's file contains the Veteran's service treatment records (STRs), VA and private medical records, and the statements of the Veteran in support of his claims. The Board has carefully reviewed the statements and concludes that there has been no identification of further available evidence not already of record. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims for which VA has a further duty to obtain. VA examinations were obtained in September 2010 and June 2011. 38 C.F.R. § 3.159(c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA has fulfilled in obligation to afford the Veteran an examination. Both examination reports reflect that the Veteran gave inconsistent responses which made the test results unreliable. In a December 2012 informal hearing presentation, the Veteran's accredited representative requested a Board remand in order to obtain another VA examination. The Board acknowledges that VA audiology testing results were invalid upon VA examinations; however, there is no competent evidence that another VA examination would produce valid test results. The Veteran has been afforded audiology examinations on two occasions and has been unable or unwilling to produce valid results on each of the two occasions. There is nothing in the record which reflects that the invalid testing was in any way due to the actions of the VA clinician or the equipment. Moreover, there are no other clinical findings which are indicative of hearing loss disability for VA purposes. The Board also notes that tinnitus can, in some situations, be related to hearing loss. Thus, as the Veteran has not provided reliable hearing test results, and has provided test results which reflect that his hearing is better than reported, an adequate opinion on tinnitus cannot be provided. As the Veteran has been afforded two audiology examinations, the Board finds that VA has fulfilled its duty to assist. The Board also acknowledges the representative's statement that the VA examiner did not address the Veteran's asserted continuity of symptomatology. The Board finds that such an opinion is not necessary. As no hearing loss disability for VA purposes has been shown, continuity of symptomatology of hearing impairment is not relevant. As discussed in further detail below, a disability for VA purposes is required for entitlement to service connection. Entitlement to service connection for hearing loss disability is somewhat unusual in that not all hearing loss is regarded as a disability. Moreover, the Board finds, as discussed below, that the Veteran is less than credible with regard to continuity of tinnitus since service; therefore, such a contention need not be discussed by an examiner. The Veteran has been informed by VA that he should provide clinical evidence of his disabilities, if he has any, yet he has not done so. In this regard, the Veteran has reported that he has had earaches treated by antibiotics; however, he has failed to provide any records with regard to his ears, or authorization for VA to obtain any such pertinent records. The duty to assist is not a one-way street. If a Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims. Legal criteria Service connection is warranted if it is shown that a Veteran has a disability resulting from an injury incurred or a disease contracted in active service or for aggravation of a pre-existing injury or disease in active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet.App. 247 (1999); Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Pursuant to 38 C.F.R. § 3.303(b), a claimant may establish the second and third elements by demonstrating continuity of symptomatology. See Barr v. Nicholson, 21 Vet.App. 303 (2007). Continuity of symptomatology can be demonstrated by showing (1) that a condition was "noted" during service; (2) evidence of continuous symptoms after service; and (3) medical, or in certain circumstances, lay evidence of a nexus between the current disability and the post service symptoms. Savage v. Gober, 10 Vet.App. 488 (1997). Where a Veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and certain diseases, such as hearing loss and tinnitus, as organic diseases of the nervous system, become manifest to a degree of 10 percent or more within one year from the date of termination of such service, such disease(s) shall be presumed to have been incurred in or aggravated by service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309 (2012). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000 and 4,000 Hertz is 40 decibels or greater; or when the thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2012). Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, 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. Bilateral Hearing Loss Disability The Veteran avers that he has a bilateral hearing loss disability as a result of active service. The first element of a claim for service connection is that there must be evidence of a current disability. The Board finds, for the reasons noted below, that this first element has not been met. The Veteran underwent a VA examination in September 2010. The examination report reflects "there was poor pure tone and speech recognition threshold (SRT) consistency. This is indicative of better than reported hearing thresholds."(Emphasis added.). The Veteran was afforded another VA examination in June 2011. The examination report reflects that "[a]udiologic findings were inconsistent. Speech reception threshold (SRT) and three frequency pure-tone average were in poor agreement bilaterally." The examiner also noted that due to inconsistent responses by the Veteran during audiometric evaluation, the reported test results are not considered to be reliable and do not provide an accurate representation of current hearing sensitivity. An April 2012 addendum reflects the same. In sum, the Veteran was afforded VA audiology examinations on two dates. On both occasions, hearing loss disability for VA purposes was not shown. In addition, there are no private medical records of evidence which reflect current hearing loss disability for VA purposes. The Veteran is competent to attest to factual matters of which he has first-hand knowledge (e.g., experiencing difficulty hearing). To this extent, the Board finds that the Veteran is competent to report that he has current hearing loss. However, the Veteran has not been shown to possess the requisite skills or training necessary to be capable of making precise diagnostic evaluations necessary for a finding of a VA disability. Diminished hearing is not synonymous with a hearing loss disability for VA purposes. The Court in Hensley v. Brown, 5 Vet. App. 155, 157 (1993) noted that the threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. However, not all hearing loss constitutes hearing loss "disability" for VA purposes. The Board may not grant the Veteran service connection when the standard for a disability has not been met. The evidence of record does not establish that the Veteran has a hearing loss disability for VA purposes. 38 C.F.R. § 3.385. As a service connection claim requires, at a minimum, medical evidence of a current disability, the Veteran's claim for service connection for bilateral hearing loss disability is not warranted in this case. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2012), but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Tinnitus The Veteran avers that he has tinnitus as a result of active service. As noted above, the first element of a claim for service connection is evidence of a current disability. The Veteran is considered competent to report tinnitus. See Charles v. Principi, 16 Vet. App. 370, 374 (2002) ("ringing in the ears is capable of lay observation"). The Veteran's DD 214 reflects that he was awarded the Korean Service Ribbon with Bronze Star, and the Republic of Korea Presidential Citation. The Veteran has also averred exposure to weapons in basic training. Some acoustic trauma is consistent with the Veteran's service in basic training and in Korea during the Korean War. However, the Board finds, for the reasons noted below, that entitlement to service connection for tinnitus is not warranted. Initially, the Board notes that there is no competent clinical opinion that the Veteran has tinnitus causally related to active service. In the absence of a competent clinical opinion, service connection may be warranted in situations where there is credible competent evidence of continuity of symptomatology since service. The Board finds that the evidence is against a finding of tinnitus since service. The Veteran's STRs are negative for any complaints of tinnitus. The Veteran's STRs reflect that in January 1954, he was seen at the ear, nose, and throat clinic for complaints of chronic sinusitis. At that time, it was noted that his ears were "negative". The Board finds that if the Veteran had had tinnitus at that time, or recurrently in the more than one year since basic training (when he contends it began), it would have been reasonable for him to have reported it when he sought treatment at an ear, nose, and throat clinic; he did not. The Veteran was also seen in January 1954 for NeuroCirculator Asthenia (Psych Cardio-vascular reaction) The January 1954 records note that the he had chest pain, shortness of breath, dizziness, and a fast beating heart. It was noted that he had not other complaints, except diarrhea. The STRs further reflect a history of typical symptoms of nervousness, to include sweaty palms and feet and palpitations. The record is negative for any complaints of tinnitus. The Veteran's 1954 report of medical examination for separation purposes reflects that the Veteran's ears were normal upon clinical examination. The Veteran filed a claim for VA compensation in April 1955, for "dizzy spells." The Board finds that if the Veteran had tinnitus since service, it would have been reasonable for him to have filed a claim for it when he filed a claim for dizzy spells; he did not do so. A November 1954 clinical record reflects that a diagnosis of "no disease of the central nervous system at this time." The Veteran again filed a claim for VA compensation in May 1961 for nervousness, dizziness, and headaches. Again, the Board finds that if the Veteran had tinnitus since service, it would have been reasonable for him to have filed a claim for it when he filed his claim for other disabilities in 1961; he did not do so. A June 1961 VA psychiatric examination report reflects that the Veteran reported, that since separation from service, he had recurrent headaches, recurrent stomach trouble, and had been feeling tired and weak. The Board finds that if the Veteran had been experiencing tinnitus since separation from service it would have been reasonable for him to have reported it when being clinically evaluated, and for it to have been noted, when he reported his other symptoms since service; he did not do so. The Board finds it noteworthy that the Veteran reported headaches which occurred approximately once a week and last three to four hours at a time, since discharge from service. The Board acknowledges that when a Veteran seeks treatment for one disability, it may not be reasonable, or even contemplated, to mention a disability of another body system; however, as the Veteran was reporting dizziness and headaches, it would not have been unreasonable for him to have mentioned ringing in the ears. To the contrary, it would have been potentially relevant for his evaluation of dizziness and headaches. The absence of any corroborating medical evidence supporting the Veteran's assertions, in and of itself, does not render his statements incredible, but that such absence is for consideration in determining credibility. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (noting that the absence of contemporaneous medical documentation may go to the credibility and weight of Veteran's lay testimony, but the lack of such evidence does not, in and of itself, render the lay testimony incredible). In May 2003, the Veteran submitted a nine page statement with regard to his disabilities. He noted that while in service, his heart "pounded", he passed out, he was weak and anxious, he was depressed, he began panicking and sweating, and his heart felt like it was skipping beats. He further stated that after service, he was anxious, had headaches, and felt dizzy. Again, there was no mention of tinnitus. In August 2004, the Veteran filed a claim for entitlement to service connection for tinnitus. He reported that he was exposed to 105 mm Howitzers for eight weeks in the military. In a statement received by VA in December 2004, the Veteran stated that he has had "ringing in the ears almost constantly since I've been out of service. Also my hearing is not too great [and] I get earaches often. In Basic I trained for 8 weeks on the 105 Howitzers [and] then the ringing started [and] it never lets up." The earliest post-service evidence of tinnitus is in 2004, approximately 50 years after separation from service. The lapse of time between service separation and the earliest documentation of current disability is a factor for consideration in deciding a service connection claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board notes that there are extensive records in evidence pertinent to the Veteran's heart disease, non Hodgkin's and lymphoma, and psychiatric disability; yet none of them mentions a complaint of tinnitus. The Board has also considered whether the Veteran is entitled to the presumptions of 38 C.F.R. § 3.304(d), but finds that he is not. If an injury or disease was alleged to have been incurred or aggravated in combat, such incurrence or aggravation may be shown by satisfactory lay evidence, if consistent with the circumstances, conditions, or hardships of service, even if there is no official record of the incident. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). However, the provisions of 38 U.S.C.A. § 1154(b) do not establish a presumption of service connection, but ease the combat Veteran's burden of demonstrating the occurrence of some in-service incident to which the current disability may be connected. See Caluza v. Brown, 7 Vet. App. 498 (1995). The statute provides a basis for determining whether a particular injury was incurred in service, but not a basis to link the injury etiologically to the current condition. Dalton v. Nicholson, 21 Vet. App. 23, 36-37 (2007); Cohen v. Brown, 10 Vet. App. 128, 138 (1997); Libertine v. Brown, 9 Vet. App. 521, 523-24 (1996). In the present case, the evidence of record does not reflect that the Veteran served directly in combat. In addition, he has alleged that his injury occurred in basic training. In sum, the Board finds, based on the record as a whole, that the Veteran is less than credible with regard to tinnitus in service or since separation. Credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements. Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995). In the present claim, the Veteran's STRs are negative for complaints of, or treatment for tinnitus, his separation examination of the ears was normal, he filed claims for VA compensation in 1955 and 1961 for other disabilities (nervousness, headaches and dizziness) but did not indicate that he also had tinnitus, and there is no competent clinical evidence of tinnitus in the five decades since separation from service. In addition, while the Veteran is competent to report tinnitus, he has not been shown to have the necessary training to render a competent etiology opinion. The Board notes that in the present claim, the Veteran was 72 years old when he reported tinnitus, he has contended that he has a hearing loss, he was a truck/trailer driver for 34 years (See November 2001 private record), and he has alleged past earaches with antibiotic treatment. He has not been shown to be competent to render an opinion as to whether his current alleged tinnitus is casually related to service, his 34 years as a truck/trailer driver, his age, his alleged hearing loss, or his past earaches. In the absence of demonstration of credible continuity of symptomatology, a competent clinical opinion relating the current tinnitus to service, or competent credible evidence of tinnitus within one year after separation, the Board finds that service connection is not warranted. 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). ORDER Entitlement to service connection for bilateral hearing loss disability is denied. Entitlement to service connection for recurrent tinnitus is denied. REMAND The Veteran contends that he has cardiac arrhythmia. As noted above, an essential element of service connection is a current disability. Based on the evidence of record the Board is unsure if the Veteran has heart palpations due to his service connected psychiatric disability or if he has cardiac arrhythmia. A January 1954 STR reflects that the Veteran had a history of typical symptoms of nervousness, to include palpitations. A January 2002 private medical record reflects that the Veteran had some "fluttering in chest" when lying down and had been treated by Dr. M.H. March 2005 correspondence from Dr. M.H. states that the Veteran has a history of palpitations and anxiety. Correspondence from Dr. M.H. received by VA in April 2006 reflects that the Veteran has cardiac arrhythmia. A November 2006 VA examination report reflects the opinion of the examiner that "it is not at least as likely as not that the palpitations are secondary to anxiety." The rationale was that the Veteran had a history of excessive alcoholism, which can cause an irregular pulse. In August 2010, the Board found that another examination was warranted because there was no objective evidence of record of alcohol abuse. A September 2010 VA examination report reflects the opinion of the examiner as follows: "After carefully reviewing the claims file and the current clinical findings, it is my opinion that there is no evidence of cardiac arrhythmia, and his palpitations are really heartbeats that the patient feels at night and not an irregular heart." In May 2011, the Board found that treatment records from Dr. M.H. to support his clinical assertion should be obtained and associated with the claims file. In May 2011 correspondence, VA requested the Veteran to provide medical evidence of cardiac arrhythmia, to include treatment by Dr. M.H. Correspondence from Dr. M. H. received by VA in July 2011 reflects the statement of Dr. M.H. that the Veteran is under care for his cardiac arrhythmia and anxiety; however, no test results were received. A June 2011 VA examination report reflects the statement of the examiner, in pertinent part, as follows: "The Holter monitor was done several years ago by his private doctor, and there was no arrhythmia noted in the Holter monitor. When he is very anxious, he gets palpitations. He gets palpitations particularly at night when he has nightmares; his heart starts beating fast. During the day just before he takes his Xanax, he gets anxious and he will get palpitations. As soon as he takes his Xanax and mirtazapine, he calms down, it relaxes him, and the palpitations ease." The Board notes that the Holter monitor results are not associated with the claims file, and the Board is unsure if the examiner was shown the results by the Veteran, or merely told the results by the Veteran. Regardless, the monitor results, if any, should be associated with the claims file if reasonably possible. The Veteran is service connected for anxiety reaction with conversion symptoms. The RO's rating was based, in part, on the Veteran's anxiety and panic attacks, and his need for medication to control such. Thus, it is important for the Board to know whether the Veteran has palpitations as a symptom of his service-connected psychiatric disability or if he has a separate disability of the heart. The Board finds that the Veteran should undergo a Holter test, or other appropriate diagnostic testing. 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) (2012). Expedited handling is requested.) 1. Request the appellant to complete and return a provided VA Form 21-4142, Authorization and Consent to Release Information, for Dr. M.H. for treatment for his heart and/or palpitations, to include the actual diagnostic results of all Holter tests which have been previously performed. After obtaining a completed VA Form 21-4142, the AOJ should attempt to obtain all pertinent medical records and associate them with the claims file. 2. Thereafter, the Veteran should be afforded a VA examination for his heart, to include Holter monitor testing. If the VA examiner determines that the Veteran has cardiac arrhythmia (e.g. atrial fibrillation or atrial fluttering) of an ischemic origin, the examiner should opine as to whether it is at least as likely as not (50 percent or greater) that it is causally related to the Veteran's military service, or proximately due to or aggravated by the Veteran's service-connected anxiety reaction with conversion symptoms and/or his service-connected coronary artery disease and/or his service-connected hypertension. The relationship, if any, should be discussed. The claims folder should be reviewed in conjunction with such examinations and the examination reports should indicate that such a review was performed. Any opinion expressed should be accompanied by a complete rationale. The Veteran should be advised that failure to appear for an examination as requested, and without good cause, could adversely affect his claim, to include denial. See 38 C.F.R. § 3.655 (2012). 3. Thereafter, readjudicate the issue of entitlement to service connection for cardiac arrhythmia. If a benefit sought is not granted, issue a supplemental statement of the case and afford the appellant and her representative an appropriate opportunity to respond. Thereafter, the case should be returned to the Board, as warranted. 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). 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. 2012). ______________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs