Citation Nr: 1306250 Decision Date: 02/22/13 Archive Date: 02/27/13 DOCKET NO. 09-29 172 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for chronic bilateral hearing loss disability. 2. Entitlement to service connection for chronic hypertension. 3. Entitlement to service connection for a chronic colon disorder to include an ascending colon polyp and sigmoid diverticula. 4. Entitlement to service connection for a chronic pulmonary disorder to include chronic obstructive pulmonary disease, airways disease, impaired breathing, and chest pain to include as due to exposure to asbestos in service or as secondary to service-connected disability. 5. Entitlement to a total rating for compensation purposes based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD N. L. Rippel, Counsel INTRODUCTION The Veteran had active service from March 1967 to February 1969. This matter came before the Board of Veterans' Appeals (Board) on appeal from a November 2008 rating decision of the Nashville, Tennessee, Regional Office (RO) which denied both service connection for bilateral hearing loss disability, hypertension, a colon disorder to include an ascending colon polyp and sigmoid diverticula, a pulmonary disorder to include chronic obstructive pulmonary disease (COPD), airways disease, impaired breathing, and chest pain and a total rating for compensation purposes based on individual unemployability. In August 2010, the Veteran was afforded a videoconference hearing before the undersigned Veterans Law Judge. The appeal was remanded by the Board to the RO via the Appeals Management Center (AMC) in January 2011 for additional development. The case has been returned to the Board for appellate review. The issues of entitlement to service connection for bilateral hearing loss disability, chronic pulmonary disorder to include chronic obstructive pulmonary disease, airways disease, impaired breathing, and chest pain, to include as due to asbestos exposure, and TDIU, are addressed in the REMAND that follows the ORDER section of this decision. The record reflects multiple instances, including most recently in a September 2012 written statement, in which the Veteran in essence asserts that he has heart disability, to include coronary artery disease, due to service. Thus, the issue of entitlement to service-connection for heart disability has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. Chronic hypertension was not present during service or in the first post-service year, and the Veteran's current hypertension is not etiologically related to service. 2. A chronic colon disorder to include an ascending colon polyp and sigmoid diverticula was not present during service or in the first post-service year, and the Veteran's current colon disorder is not etiologically related to service. CONCLUSIONS OF LAW 1. Hypertension was not incurred in active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). 2. A chronic colon disorder to include an ascending colon polyp and sigmoid diverticula was not incurred in active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran asserts that service connection for chronic hypertension and a chronic colon disorder is warranted as he has chronic hypertension that was caused by in-service noise exposure and he has chronic colon disorder caused by his intake of fatty foods during active service and beyond. Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in pertinent part at 38 U.S.C.A. §§ 5103 , 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. Although the regulation previously required VA to request that the claimant provide any evidence in the claimant's possession that pertains to the claim, the regulation has been amended to eliminate that requirement for claims pending before VA on or after May 30, 2008. The Board also notes the Court has held the plain language of 38 U.S.C.A. § 5103(a) requires notice to a claimant pursuant to the VCAA be provided "at the time" or "immediately after" VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement articulated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The record reflects that the Veteran was provided all required notice in letters mailed in January 2008 and June 2008, prior to the initial adjudication of the claims. The Board also finds the Veteran has been afforded adequate assistance in regard to the claims. The Veteran's service treatment records (STRs) are associated with his claims file, and pertinent, available, post-service treatment records have been secured. Evidentiary development in this matter is complete to the extent possible. The Veteran has not identified any other pertinent evidence that remains outstanding, and in fact reported in September 2012 that he had submitted all information he had in support of his appeal. Additionally, in December 2012, the Veteran's representative waived consideration of evidence submitted by the Veteran subsequent to the issuance of the September 2012 supplemental statement of the case by the agency of original jurisdiction (AOJ). Accordingly, VA's duty to assist is met. Moreover, VA substantially complied with the Board's remand instructions of January 2011. By way of a January 2011 letter, the Appeals Management Center contacted the Veteran and requested that he identify any additional medical records relevant to his claims. Additional VA treatment records and Social Security Administration (SSA) records have been obtained and the Veteran was afforded VA examinations for his claims in May 2011. With respect to the Board hearing, the Court of Appeals for Veterans Claims held in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. 3.103(c)(2) requires that the RO official or VLJ who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ noted the current appellate issue at the beginning of the hearing, and asked questions to clarify the Veteran's contentions. Following the hearing, the case was remanded in order to obtain additional VA, SSA and any other sufficiently identified records and to afford the Veteran a VA examination. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. Accordingly, the Board will address the merits of the claim. Law and Regulations Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304. For veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as hypertension or malignant tumors, may be presumed to have been incurred or aggravated in service if manifest to a compensable degree within one year after discharge from service. 38 U.S.C.A. §§ 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Factual Background and Analysis The Board notes that it 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 its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. The Veteran urges that he has hypertension due to exposure to acoustic trauma experienced in connection with his duties in service. Specifically, he testified that it is his belief that close proximity to artillery, including 6 inch howitzers, on a routine basis, caused him to have hypertension. As to colon disease, he urges that eating fatty foods in service and for many years following service caused this disease. The Veteran's DD 214 reflects that he was a radio relay operator. He also testified that his secondary duties were related to infantry and he had exposure to artillery in his TDY as artillery support. It is not disputed that he was exposed to acoustic trauma in service. STRs include examination reports showing that the Veteran entered service in March 1967 and separated from service in February 1969 with normal clinical evaluations with regard to his anus and rectum and abdomen. His blood pressure was 132/78 at entrance and 134/86 at separation. In a February 1969 report of medical history at separation, the Veteran denied having or ever having high blood pressure, or stomach, liver or intestinal trouble. There was no treatment for colon related problems in the STRs, nor was there any mention of hypertension. In his claim form received in January 2008, the Veteran indicated that his hypertension began in June 2004 and colon disability began in June 2007. VA treatment records show a diagnosis of hypertension dating from October 2007. The first evidence of colon problems in the record is a December 2007 report following colonoscopy, prompted by occult blood in the stool, showing ascending colon polyp and sigmoid diverticula. Additional treatment records have continued to note the presence of these disabilities but do not contain any suggestion of a link between these disabilities and service or the specific in-service causes alleged by the Veteran. SSA records consist in large part of copies of VA treatment records but also include a medical assessment dated in August 2008. Although this report focuses largely on the effects of the Veteran's coronary artery disease, status post two vessel bypass, with residual chest pain, it also notes past medical illnesses and history to include hypertension. Also noted is polypectomy of the colon and the Veteran reported he was told he had a 'small' cancer that did not require chemo or radiation therapy. On examination, blood pressure was 140/84, and bowel sounds were positive x4. Diagnoses included hypertension and status post colonoscopy with small CA. The Veteran was afforded a VA examination in May 2011 to assess the disabilities at issue. The examiner indicated in the report of examination that the claims folder had been reviewed. When questioned about the onset of his hypertension, the Veteran did not recall. He noted that he was initially treated in Greenville, Tennessee for hypertension with beta blockers but he had adverse effects. His medications were changed and his blood pressure had stabilized. It was noted that he had a myocardial infarction in 2008. His blood pressures were 140/80, 138/78 and 126/82. The diagnosis was essential hypertension. The examiner next examined the Veteran for colon disability. The Veteran did not know the date of onset of this disability but noted the initial manifestation was in 2007 with the colonoscopy which the VA examiner noted showed ascending polyp, biopsy, tubular adenoma, with recommended follow up in five years. He had not had recurrences as the course was noted as stable. Examination revealed no indication of abnormal colic, vomiting, abdominal distension, or other findings consistent with partial bowel obstruction. The diagnosis following examination was diverticulosis and colon polyp, adenoma. The examiner opined that the Veteran's chronic essential hypertension was not caused by or the result of active service nor was it related to the Veteran's in-service noise exposure or otherwise related to active service. She explained that STRs do not show any treatment for hypertension, and his risk factors include family history, male gender, obesity and high cholesterol. She opined that his chronic colon disorder is not caused by or the result of military service nor is it related to in-service consumption of fatty foods. The rationale for this was that diverticula are common after age 40. She added that, according to mayoclinic.com, they develop when naturally weak places in one's colon give way under pressure. This causes marble-sized pouches to protrude through the colon wall. Per the same resource, anyone can develop colon polyps. One is at a higher risk if at age 50 or older, are overweight, a smoker, eat a high fat-low fiber diet, or have a personal or family history of colon polyps or colon cancer. The Veteran is over age 50, has a long history of obesity and has a personal family history of colon cancer. Moreover, he was out of the military almost 40 years before a polyp was diagnosed. The RO denied the claims in November 2008, and the AMC continued to deny the claims in September 2012, based on the findings of no hypertension or colon disability in service or until many years after service, and no indication that the current disabilities were related to service. It is not in dispute that the Veteran now has hypertension or colon disease as indicated in the record. However, it is neither alleged, nor shown by the record, that these disabilities were present in service nor manifested in the Veteran's first year post-service. Furthermore, there is no medical opinion in the record that directly relates these disabilities to service or to any event therein. The documented record as well as the uncontroverted medical opinion of record is wholly against such a finding. The Board finds the medical opinion contained in the May 2011 VA examination report to be well-supported and based on a physical examination and factual predicate that is not inconsistent with the documented record. As such, it is accorded significant probative weight as to whether the disabilities are related to service. The Veteran may establish service connection by affirmative and competent evidence that such diseases are related to his service or some event therein. However, as noted above, the first evidence of diagnosis of these disabilities is many years after the Veteran's discharge from service in 1969. Such a long interval between service and the initial diagnosis is, of itself, a factor against a finding that these disabilities are service-related. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) [noting that it was proper to consider the veteran's entire medical history, including the lengthy period of absence of complaint with respect to the condition he now raised]; see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) [affirming Board where it found that veteran failed to account for the lengthy time period after service for which there was no clinical documentation of the claimed condition]. Furthermore, there is no competent evidence that links disabilities to the Veteran's service. The Veteran believes that his disabilities are related to service as detailed elsewhere in this decision. In this regard, the Board acknowledges Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), in which it was held a lay person may speak as to etiology in some limited circumstances in which nexus is obvious merely through lay observation. Here, however, medical expertise is required to answer the question of whether the Veteran's current hypertension or colon disease is related to his active service. The Veteran's lay opinion concerning these matters requiring medical expertise is of no probative value as the etiology of these matters is beyond his capability to observe as a lay person. Moreover, the evidence does not show that these disorders were manifested in service, to include upon the separation examination, and the Veteran does not assert continuity of symptomatology. Instead, he indicated in his claim form that these disabilities began many years after service. Accordingly, the Board must conclude that the preponderance of the evidence is against the Veteran's claims for service connection on a direct or on a presumptive basis (as a chronic disease under 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309). ORDER Service connection for chronic hypertension is denied. Service connection for a chronic colon disorder to include an ascending colon polyp and sigmoid diverticula is denied. REMAND The Board finds that additional development is warranted as to the issue of service connection for hearing loss disability. The Veteran testified before the undersigned that he was exposed to acoustic trauma in service, that his hearing loss was first noted by one of his commanding officers in service and that it has continued to the present. Although not directed to do so in the Board's January 2011 Remand, the AMC ordered an audiological evaluation. The May 2011 report of this examination reflects that the examiner made a diagnosis of bilateral sensorineural hearing loss, but did not opine as to the etiology of the current hearing loss. A report of audiological evaluation dated in October 2008 reflects the examiner's opinion that the Veteran had bilateral sensorineural hearing loss that was less likely as not caused by an in-service event. The examiner noted that the Veteran already had hearing loss at induction into service, as noted in his March 27, 1967, induction evaluation, and no progression was noted in his separation examination dated February 5, 1969, as it showed the same amount of hearing loss. The examiner failed to comment on the additional audiogram results located on the front of the examination report and dated March 28, 1967, which indicated different results. Parenthetically, the Board notes that prior to November 1967, service department audiometric results were reported in standards set forth by the American Standards Association (ASA). Since November 1, 1967, those standards have been set by the International Standards Organization (ISO)-American National Standards Institute (ANSI). It is not clear whether either of the March 1967 audiological findings have been converted to the ISO standard or whether the examiner in 2008 considered any such converted data. In December 2012 argument, the Veteran's representative argues that there is decibel loss at the 2000 and 4000 Hertz ranges between the March 28, 1967, report and the separation examination. The representative argues that this supports the claim for service connection. This was not addressed in either examination report. Additionally, the October 2008 VA examiner did not discuss whether or not the required conversion to ISO-ANSI units from the ASA units was performed prior to providing an opinion that the Veteran's current hearing loss was not related to service given the history of noise exposure therein. The Board notes that, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examinations of record are incomplete and inadequate. As to lung disability, the record reflects that the Veteran received albuterol breathing treatments in March 2008 for complaints of shortness of breath following coronary artery bypass grafting (CABG) in March 2008. He was also put on home oxygen at that time. On March 19, 2008, he was noted to have significant mediastinal collection status post CABG. A follow-up appointment in May 2008 revealed COPD and post operative pain. He was discharged from the pulmonary clinic in May 2008 with the assessments of hypoxia post CABG, etiology unclear, but may have been related to effusions and post operative pain. Chest computerized tomography showed improvement. Also noted was small airway disease. The Veteran now urges that he has service-connected lung disease due to asbestos exposure in service, or, in the alternative, due to heart disease. He urges that he was exposed to asbestos in his work with radio rigs and generators in the Army. As noted, a claim for service connection for heart disease is being referred to the originating agency in this decision. Under the circumstances, the Board finds that additional development is necessary as to this claim prior to appellate review. VA's duty to assist includes a duty to provide a medical examination or to obtain a medical opinion where it is deemed necessary to make a decision on the claim 38 U.S.C.A. § 5103A(d) (West 2002); 38 C.F.R. § 3.159(c)(4) (2012); Robinette v. Brown, 8 Vet. App. 69 (1995). In a claim for service connection, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits still triggers the duty to assist if it indicates that the Veteran's condition may be associated with service. McLendon v. Nicholson, 20 Vet. App. 79 (2006) (38 C.F.R. § 3.159(c)(4) presents a low threshold for the requirement that evidence indicates that the claimed disability may be associated with in-service injuries for the purposes of a VA examination). With asbestos related claims, VA must determine whether military records demonstrate asbestos exposure during service, and if so, determine whether there is a relationship between asbestos exposure and the claimed disease. M21-1MR, Part VI, Subpart ii, Chapter 2(C)(9)(h). VA must also ensure that proper development of the evidence is accomplished to determine whether or not there is pre-service and/or post- service asbestos exposure. Id. The most common disease caused by exposure to asbestos is interstitial pulmonary fibrosis (asbestosis). Asbestos fibers may also produce pleural effusions and fibrosis, pleural plaques, and mesotheliomas of the pleura and peritoneum, lung cancer, and cancers of the gastrointestinal tract. M21-1MR, Part VI, Subpart ii, Chapter 2(C)(9)(b). The clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal lung disease. M21-1MR, Part VI, Subpart ii, Chapter 2(C)(9)(e). Some of the major occupations involving exposure to asbestos include mining, milling, work in shipyards, insulation work, demolition of old buildings, carpentry and construction, manufacture and servicing of friction products such as clutch facings and brake linings, manufacture and installation of roofing and flooring materials, asbestos cement and pipe products, military equipment, etc. M21-1MR, Part VI, Subpart ii, Chapter 2, §C(9)(f). The relevant factors discussed in the manual must be considered and addressed by the Board in assessing the evidence regarding an asbestos-related claim. See VAOPGCPREC 4-2000. Here, personnel records note that the Veteran served in the Army in Germany as a radio operator. His service treatment records are negative for findings of lung cancer or lung disability. Current lung diagnoses include acute bronchitis and COPD in August 2012. VA examination in May 2011 revealed pulmonary function testing with mild decrease in diffusion capacity, which is often seen in emphysema, interstitial lung disease and pulmonary vascular disease. Although the VA examiner reports that the Veteran's claims file was reviewed, he did not include any specific discussion of the possible asbestos-related disease. Therefore, a medical opinion is needed to as to whether the Veteran's lung disease is related to claimed asbestos exposure in service. Prior to the examination, full development of the lung disability claim should be undertaken in compliance with VA guidelines regarding asbestos claims. Based on the Board's decision to remand the Veteran's claims of entitlement to service connection for bilateral hearing loss disability and lung disability, the Board finds that the Veteran's claim of entitlement to a total disability rating based on individual unemployment (TDIU) is inextricably intertwined with the service-connection claims. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (noting that two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). In this regard, the Board notes that the Veteran's recent argument that he has not worked in six months due to his disabilities, to include bilateral hearing loss, heart and lung disabilities. In addition, the Veteran testified that he started to have hearing tests in 1981. On remand, the Veteran should be asked to provide or sufficiently identify the records so VA can attempt to obtain them on his behalf. Also, as the Veteran receives medical care through VA, recent VA treatment records not already of record should also be obtained. See Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA has constructive notice of VA generated documents that could reasonably be expected to be part of the record). Accordingly, this case is REMANDED to the RO or AMC, in Washington, D.C., for the following actions: 1. Inform the Veteran as to how to substantiate his claim for service connection for a lung disorder as secondary to a service-connected disability. 2. Request that the Veteran provide or identify any additional medical records that are relevant to his claims, including any hearing tests dating from 1981 that are not already of record. If, after making reasonable efforts to obtain named records the AMC is unable to secure same, the AMC must notify the Veteran and (a) identify the specific records the AMC is unable to obtain; (b) briefly explain the efforts that the AMC made to obtain those records; (c) describe any further action to be taken by the AMC with respect to the claim; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 3. Obtain any recent VA treatment records that have not already been associated with the claims folder or the Veteran's virtual VA record. 4. Obtain a VA medical opinion by an appropriate VA examiner regarding the Veteran's claim for service connection for bilateral hearing loss disability. The claims file should be provided to the examiner for review, and the examiner should note that it has been reviewed. After reviewing the file, the examiner should clarify the Veteran's current relevant diagnosis or diagnoses, if any. Additionally, the examiner should do the following: a. State whether it is at least as likely as not (a probability of 50 percent or greater that the hearing loss noted upon entry to service was aggravated on the right and left side (i.e., permanently increased in severity) during that period of service. Please provide a complete explanation for the opinion. In this regard, on the March 27, 1967, audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 (20) -5 (5) 10 (20) 45 (50) LEFT 10 (25) 15 (25) 30 (40) 60 (65) On the audiological evaluation on March 28, 2967, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 (25) 15 (25) 20 (30) 35 (40) LEFT 20 (35) 25 (35) 40 (50) 50 (55) In order to facilitate data comparison, the ASA standards have been converted to ISO-ANSI standards and are represented by the figures in parentheses. b. If so, was any increase clearly and unmistakably (obviously, manifestly or undebatably) due to the natural progress of the disease. Please provide a complete explanation for the opinion. The examiner's attention is directed to the Veteran's in-service diagnosis of defective hearing at induction, his credible assertions that he had acoustic trauma during service, and the recent findings of bilateral sensorineural hearing loss disability. If the examiner determines that an examination is necessary in order to provide the requested information, then one should be scheduled. Note: Aggravation indicates a permanent worsening of the underlying condition as compared to an increase in symptoms. 5. Complete all development necessary for asbestos-related claims, pursuant to M21-1MR, Part VI, Subpart ii, Chapter 2, §C(9)(h). 6. Thereafter, the Veteran should be afforded a VA examination to determine the nature and etiology of any currently present lung disability. The claims file must be made available to and reviewed by the examiner. Any indicated studies should be performed. Based on the examination results and a review of the record, the examiner should provide an opinion with respect to each lung disorder present during the period of the claim as to whether it is at least as likely as not (a 50 percent or better probability) that the disorder is related to the Veteran's active service, to include claimed exposure to asbestos in service. The examiner's attention is directed to the VA examination in May 2011 which included pulmonary function testing showing a mild decrease in diffusion capacity, which is often seen in emphysema, interstitial lung disease and pulmonary vascular disease. The examiner should also address whether it is at least as likely as not that any current lung disease is due to the Veteran's heart disorder. The examiner should also address whether it is at least as likely as not that any current lung disease is aggravated (i.e., worsened) beyond the natural progress by the heart disease. If aggravation is found, the examiner should address the following medical issues: (1) the baseline manifestations of the Veteran's lung disorder(s) found prior to aggravation; and (2) the increased manifestations which, in the examiner's opinion, are proximately due to the heart disability. The supporting rationale for all opinions expressed must be provided. 7. The RO or the AMC should also undertake any other development it determines to be warranted and then, after ensuring the examination report is adequate, the RO or the AMC should readjudicate the issues of service connection for bilateral hearing loss disability and lung disability, including as secondary to service-connected disability or related to asbestos exposure, and TDIU. [NOTE: the TDIU and lung disorder issues are inextricably intertwined with the issue pertaining to service connection for a heart disorder that was referred to the agency of original jurisdiction in the Introduction.] If the benefits sought on appeal are not granted to the Veteran's satisfaction, he and his representative should be furnished a supplemental statement of the case and afforded the requisite opportunity to respond before the case is returned to the Board for further appellate action. By this remand the Board intimates no opinion as to any final outcome warranted. The appellant need take no action until he is otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. 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). ______________________________________________ S. S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs