Citation Nr: 1306589 Decision Date: 02/26/13 Archive Date: 03/01/13 DOCKET NO. 08-22 855 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for diabetes mellitus. 2. Entitlement to service connection for a left eye condition, to include optic neuropathy, as secondary to diabetes mellitus. 3. Entitlement to service connection for peripheral neuropathy of the lower extremities as secondary to diabetes mellitus. 4. Entitlement to service connection for erectile dysfunction as secondary to diabetes mellitus. 5. Entitlement to service connection for urinary problems as secondary to diabetes mellitus. 6. Entitlement to service connection for hip pain and bilateral leg cramps as secondary to diabetes mellitus 7. Entitlement to service connection for tinnitus of the left ear. 8. Entitlement to service connection for a digestive disorder, to include diverticulitis, gastroesophageal reflux disease, duodenitis, and antral gastritis. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services ATTORNEY FOR THE BOARD C. Hancock, Counsel INTRODUCTION The Veteran served on active duty from April 1985 to October 1992. These matters come before the Board of Veterans' Appeals (Board) on appeal from October 2006 and January 2008 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The October 2006 rating decision, in pertinent part, denied reopening a claim for entitlement to service connection for a digestive disorder. When the case was before the Board in April 2010, the claim for entitlement to service connection for a digestive disorder was reopened and remanded. The claim was again remanded by the Board in April 2011. The January 2008 rating decision denied entitlement to service connection for diabetes mellitus, a left eye condition, peripheral neuropathy of the lower extremities, erectile dysfunction, urinary problems, hip pain with bilateral leg cramps, and tinnitus. The Board remanded these claims in April 2011 so that certain due process concerns could be addressed, and so that additional development of the evidence could be conducted. The United States Court of Appeals for Veterans Claims (Court) has held "that a remand by this Court or the Board confers on the Veteran or other claimant, as a matter of law, a right to compliance with the remand orders." See Stegall v. West, 11 Vet. App. 268, 271 (1998). The purpose of the remand was to ensure that certain medical records were initially reviewed by the AOJ (Agency of Original Jurisdiction) and so that specifically-identified VA outpatient treatment records could be sought. A review of the post-remand record shows that this ordered development was, to the extent possible, successfully completed. Therefore, the Board determines that compliance has now occurred with the Board's orders in the remand, and that the Board may now proceed with adjudication of these claims. The issue of entitlement to service connection for a digestive disorder, to include diverticulitis, gastroesophageal reflux disease, duodenitis, and antral gastritis is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Diabetes mellitus was not affirmatively shown to have been present during service; diabetes mellitus, as a chronic disease was not manifested to a compensable degree within one year from the date of separation from service; and diabetes mellitus, first diagnosed after service beyond the one-year presumptive period for a chronic disease, is otherwise unrelated to an injury, disease, or event in service. 2. A left eye condition has not been linked by competent evidence to any service-connected disorder. 3. Peripheral neuropathy of the lower extremities has not been linked by competent evidence to any service-connected disorder. 4. Erectile dysfunction has not been linked by competent evidence to any service-connected disorder. 5. A chronic disorder manifested by urinary problems has not been linked by competent evidence to any service-connected disorder. 6. Hip pain and bilateral leg cramps has not been linked by competent evidence to any service-connected disorder. 7. Ringing of the ears has not been attributed to service and there is no credible evidence of symptoms between service discharge and 2007. CONCLUSIONS OF LAW 1. Diabetes mellitus was not incurred in or aggravated by service; and diabetes mellitus, as a chronic disease, may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1110, 1112, 1131, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. A left eye condition was not caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.310 (2012). 3. Peripheral neuropathy of the lower extremities was not caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.310 (2012). 4. Erectile dysfunction was not caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.310 (2012). 5. A disorder manifested by urinary problems was not caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.310 (2012). 6. Hip pain and bilateral leg cramps was not caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.310 (2012). 7. Tinnitus was not incurred in active duty service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties To Notify And Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA 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, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Additionally, this notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. As for the claims seeking service connection, which all here are being denied, in an April 2007 letter the RO, addressing the issues pertaining to the Veteran's claims concerning diabetes, a left eye disorder, and tinnitus, notified the Veteran of the information and evidence to substantiate his service connection claims, and of what part of that evidence he was to provide and what part VA would attempt to obtain for him. The letter advised the Veteran to submit or identify any additional information that he felt would support his claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2011); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The letter also included the following enclosures: "How You Can Help and How VA Can Help You," "What the Evidence Must Show - Service connected comp," and "What the Evidence Must Show - Secondary [Service Connection]." The letter also included timely Dingess notice. For the reasons discussed above, therefore, the Board finds that, as to these claims, VA has fulfilled its VCAA notification duties to the Veteran to the extent necessary. As to the claims seeking service connection for peripheral neuropathy of the lower extremities, erectile dysfunction, urinary problems, hip pain with bilateral leg cramps, all claimed to be secondary to the Veteran's diabetes, which are also being denied, a November 2009 Statement of the Case (SOC) notified the Veteran of the information and evidence to substantiate his service connection claims, and of what part of that evidence he was to provide and what part VA would attempt to obtain for him. The SOC also provided pertinent regulations, including those concerning direct and secondary service connection. Although this notice letter postdated the initial adjudication, no prejudice resulted as the claims were subsequently readjudicated. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of fully compliant notification followed by readjudication of the claim, such as a SOC of Supplemental SOC (SSOC), is sufficient to cure a timing defect). To this, the RO provided an SSOC in November 2012 which reported the results of its review of the issues on appeal. Also, the Veteran, concerning these matters, has not been provided notice of the type of evidence necessary to establish a disability rating or effective date for the specific claims of entitlement to service connection. Despite this failure the Board finds no prejudice to the Veteran in proceeding with the issuance of a final decision. In this regard, the preponderance of the evidence is against the appellant's claims for service connection, and any questions as to what would be an appropriate disability rating and effective date to be assigned are moot. Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claims. There is no evidence of any failure on the part of VA to further comply with VCAA that reasonably affects the outcome of this case. Finally, the duty to assist the appellant has been satisfied in this case. The Veteran's service treatment records, and VA and private medical records are in the claims file and were reviewed by both the RO and Board in connection with the appellant's claims. The appellant has not informed VA of any outstanding existing medical records which may be helpful in the adjudication of his claims. VA is not on notice of any evidence needed to decide the claims which has not been obtained. The Board acknowledges that the Veteran has not had a VA examination specifically for his current claims seeking service connection. The case of McLendon v. Nicholson, 20 Vet. App. 79 (2006), held that 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. The Board concludes an examination is not needed in this case because the Veteran's service treatment/personnel records are absent for evidence of findings related to the Veteran's currently-claimed disorders, and his post-service medical records are absent for evidence of symptomatology related to any of the claimed disorders until many years after the Veteran's separation from service. See Duenas v. Principi, 18 Vet. App. 512, 519 (2004) (finding no prejudicial error in Board's statement of reasons or bases regarding why a medical opinion was not warranted because there was no reasonable possibility that such an opinion could substantiate the Veteran's claim because there was no evidence, other than his own lay assertion, that "'reflect[ed] that he suffered an event, injury[,] or disease in service' that may be associated with [his] symptoms"); see also Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (noting that a veteran's conclusory generalized statement that a service illness caused his present medical problems was not enough to entitle him to a VA medical examination since all veterans could make such a statement, and such a theory would eliminate the carefully drafted statutory standards governing the provision of medical examinations and require VA to provide such examinations as a matter of course in virtually every disability case). The first medical record on file pertaining to any of the Veteran's claimed disorders is dated in 1998. See December 1998 private medical record, which includes a diagnosis of new onset diabetes mellitus. No diagnosis pertaining to, or mention of, a left eye condition, peripheral neuropathy of the lower extremities, erectile dysfunction, urinary problems, hip pain and bilateral leg cramps, or tinnitus of the left ear, is part of any medical record on file. In addition, there is no indication that the Veteran's diabetes mellitus may be related to his service. See Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003) (noting that the Board has no obligation to obtain a medical opinion when there is no competent evidence that the appellant's disability or symptoms are associated with his service). Accordingly, it is not necessary to obtain a medical examination or medical opinion in order to decide the claims in this case. 38 C.F.R. § 3.159(c)(4)(i); see Duenas, 18 Vet. App. at 517, citing Paralyzed Veterans of Am. V. Sec'y of Veterans Affairs, 345 F.3d 1334, 1355-57 (Fed. Cir. 2003) (noting that a medical examination conducted in connection with claim development could not aid in substantiating a claim when the record does not already contain evidence of an in-service event, injury, or disease). The Board concludes the Veteran was provided the opportunity to meaningfully participate in the adjudication of his claims and did in fact participate. Washington v. Nicholson, 21 Vet. App. 191 (2007). Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. Contentions As part of a VA Form 21-4138, received in February 2007, the Veteran sought service connection for diabetes, a left eye disorder (to include an enlarged nerve in the back of the eye), and tinnitus in his left ear. A May 2007 VA Form 21-4138 shows that the Veteran claimed that he had peripheral neuropathy of his lower extremities (feet), erectile dysfunction, urinary problems, and hip pains and leg cramps, with all these cited disorders being secondary to diabetes. Laws and Regulations Service connection means that the facts establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). Alternatively, when a chronic disease is not present during service, service connection may be established under 38 C.F.R. § 3.303(b) by evidence of continuity of symptomatology. In adjudicating a claim, including as to continuity of symptomatology, the Board must assess the competence and credibility of the veteran. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board also has a duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). The Veteran is competent to provide facts about what he experienced; for example, he is competent to report that he engaged in certain activities in service and currently experiences certain symptomatology. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). Competency, however, must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). The Board acknowledges that it cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan, at 1337. However, such lack of contemporaneous evidence is for consideration in determining credibility. Establishing service connection generally requires competent evidence of the following: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a 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). If a veteran served 90 days or more on active duty, service incurrence will be presumed for certain chronic diseases, such as diabetes mellitus, Type 2, if the disease became manifest to a compensable degree within the year after active service. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307(a), 3.309(a). Also, service connection may be established on a legal presumption based on herbicide exposure where a veteran served on active duty in the Republic of Vietnam during the Vietnam era and has a certain listed disability. See 38 U.S.C.A. § 1116 (West 2002 & Supp. 2012); 38 C.F.R. § 3.307(a)(6)(iii) (2012). Diabetes mellitus is a disability associated with herbicide exposure. However, the Veteran did not serve in Vietnam, and he has not alleged being exposed to herbicides. Thus, this presumption would not apply to this case. A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). This includes any increase in severity of a nonservice-connected disease that is proximately due to or the result of a service-connected disability as set forth in 38 C.F.R. § 3.310(b). See also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). However, as discussed below, the secondary service connection claims for a left eye disorder, peripheral neuropathy of the lower extremities, erectile dysfunction, urinary problems, and hip pain and leg cramps are premised on a positive finding to a link to diabetes mellitus. Since service connection for diabetes mellitus is herein denied, 38 C.F.R. § 3.310 is of no avail to the claim. Factual Background The service treatment records include a March 1985 enlistment examination which shows that, pertaining to the claimed issues on appeal, clinical evaluation of the Veteran was normal. He also denied a prior history of any of these disorders. An April 1985 health record notes that ophthalmoscopy examination was within normal limits. In June 1991 the Veteran was seen for complaints of a sore left eye. See health record. He complained of blurriness, and denied any known injury. Dacrocystitis was diagnosed. Dacrocystitis is defined as inflammation of the lacrimal sac. See Stedman's Medical Dictionary 457 (27th ed., 2000). A July 1992 health record shows that no bilateral eye pathology was found in the course of examination. In addition, A report of medical examination dated in August 1992 does not show findings relating to any of the Veteran's instantly-claimed disorders. The Veteran was afforded a VA examination in November 1992. None of his claimed disorders was diagnosed at that time. A December 1998 private medical record shows that the Veteran had new onset diabetes mellitus. A July 2000 private medical record includes a diagnosis of noninsulin-dependent diabetes mellitus, which was described as being out of control. An October 2005 VA eye examination report shows that a past medical history of Type II diabetes mellitus, without complications was reported. The Veteran complained of difficulty focusing with his left eye. Left eye optic neuropathy was diagnosed. A January 2009 VA eye examination report shows that optic atrophy was diagnosed. This was noted to be likely related to the Veteran's diabetes. No diabetic retinopathy was shown. Bilateral cataracts were present, though not found to be visually significant. Similar findings were reported in the course of a May 2010 VA eye examination. A May 2011 VA outpatient treatment record includes a diagnosis of Type II diabetes mellitus. A November 2011 VA outpatient treatment record includes a diagnosis of diabetes mellitus. Medical records were also reviewed contained within the Virtual VA paperless claims processing system. In this system, instead of paper, a highly secured electronic repository is used to store and review every document involved in the claims process. The use of this system allows VA to leverage information technology in order to more quickly and accurately decide an appellant's claim for benefits. A September 1995 VA blood work testing record, showing normal glucose levels. A December 2002 VA ophthalmology consult shows that the Veteran did not have evidence of diabetic retinopathy. An August 2004 VA primary care outpatient record reveals complaints of one day of dysuria, with no hematuria. An August 2012 VA eye examination report shows a diagnosis of left eye optic atrophy. A diagnosis of diabetes without retinopathy was also included. Analysis Diabetes Mellitus Based on the service treatment records alone, diabetes mellitus (including Type II) was not affirmatively shown to have been present in service, and service connection under 38 U.S.C.A. §§ 1110 and 1131 and 38 C.F.R. § 3.303(a) is not established. Also, the Veteran does not argue and there is no evidence either contemporaneous with or after service that diabetes mellitus, Type 2 was noted in service, that is, observed, and the principles of service connection pertaining to chronicity and continuity of symptomatology under 38 C.F.R. § 3.303(b) do not apply. On the question of whether service connection may be granted on the basis that the claimed disability was first diagnosed after service, considering all the evidence, including that during and after service, under 38 C.F.R. § 3.303(d), the Veteran does not argue in his pleadings, namely, his application, notice of disagreement, or substantive appeal and the record does not contain competent evidence, lay or medical, that links diabetes mellitus, Type 2 to an injury, disease, or event in service, including exposure to Agent Orange, to which the veteran has not alleged that he was exposed. Also, as noted above, contemplating his dates of service, and upon a reading of the regulatory language set out as part of 38 C.F.R. § 3.307(a)(6)(iv), the veteran is precluded from being service connected for diabetes in this manner. In the absence of competent evidence suggesting such an association, and in the absence of credible evidence of continuity of symptomatology, there is no possible association with service, and VA is not required to further develop the claim on the theory of direct service connection under 38 C.F.R. § 3.303(d), as noted above, by affording the Veteran a VA examination or by obtaining a VA medical opinion under the duty to assist. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4) ; McLendon, supra. It is the Veteran's general evidentiary burden to establish all elements of his claim, including the nexus requirement under 38 C.F.R. § 3.303(d). 38 U.S.C.A. § 5107(a); Fagan v. Shinseki, 573 F.3d. 182, 1287 (2009). In the absence of any such competent evidence, the preponderance of the evidence is against the claim that diabetes mellitus, Type 2 was due to an injury, disease, or event in service, excluding exposure to Agent Orange, under 38 C.F.R. § 3.303(d), or under 38 U.S.C.A. §§ 1110 and 1131 and 38 C.F.R. § 3.303(a) and (b) as previously discussed. After service, diabetes mellitus was first diagnosed in 1998. This is six years after service, which is well beyond the one-year presumptive period following separation from service in 1992 for diabetes mellitus, as a chronic disease under 38 U.S.C.A. § 1112 and 38 C.F.R. §§ 3.307, 3.309. Accordingly, a preponderance of the evidence is against service connection for diabetes mellitus, Type 2, on the basis of any of the above theories. Also, again, as the Veteran is not shown to have been exposed to Agent Orange, nor has he so contended, presumptive service connection based on exposure to Agent Orange does not apply. As there is no competent or credible evidence of exposure to Agent Orange during the Veteran's service, the preponderance of the evidence is against service connection for diabetes mellitus, Type 2 under the presumptive provisions of 38 U.S.C.A. § 1116 and 38 C.F.R. §§ 3.307(a)(6) and 3.309(e), and the benefit of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Left Eye Condition, Peripheral Neuropathy of the Lower Extremities, Erectile Dysfunction, Urinary problems, and Hip Pain and Bilateral Leg Cramps The Veteran essentially asserts that service connection for these five disorders is warranted as he has such disorders secondary to diabetes mellitus. As mentioned, the provisions of 38 C.F.R. § 3.310 provide that service connection may be granted where a disability is proximately due to or the result of already service-connected disability. Compensation is also payable when service-connected disability has aggravated a non-service-connected disorder. Allen, supra. For the reasons explained above, the Veteran is not service-connected for diabetes mellitus. Therefore, entitlement to secondary service connection for these disorders secondary to diabetes mellitus must also be denied as a matter of law. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (where the law and not the evidence is dispositive, the Board should deny the claim on the ground of lack of legal merit). Left Ear Tinnitus After having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence on file is against a grant of service connection for a tinnitus. Subsequent to service, the Veteran initially sought service connection for this disorder in 2007. See VA Form 21-4138. A June 1987 service treatment record shows the Veteran was poked in the left ear with a Q-tip. There was no diagnosis of tinnitus at that time. In the Veteran's statements since he submitted his claim for service connection for tinnitus in 2007, he has not provided any statements regarding ringing in the ears. Rather, he simply alleges that he has tinnitus due to service. There is a lack of evidence regarding when the Veteran believes tinnitus or ringing of the ears occurred. The Board finds there is a lack of evidence that the Veteran has a current disability due to a disease or injury in service. Since service discharge, the Veteran has been treated for multiple disabilities. Examiners have examined the Veteran's ears during physical examinations, and at no time prior to 2007 did the Veteran report any ringing of the ears. Thus, the Board finds there is no credible evidence of symptoms of tinnitus between service discharge and 2007. Thus, the Veteran's allegation in 2007 that he has tinnitus due to service is found not credible. Accordingly, the Board finds the preponderance of the the evidence is against a finding that any current ringing of the ears is due to service. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt-rule is not applicable. 38 U.S.C.A. § 5107(b), Gilbert. ORDER Entitlement to service connection for diabetes mellitus is denied. Entitlement to service connection for a left eye condition, to include optic neuropathy, as secondary to diabetes mellitus is denied. Entitlement to service connection for peripheral neuropathy of the lower extremities as secondary to diabetes mellitus is denied. Entitlement to service connection for erectile dysfunction as secondary to diabetes mellitus is denied. Entitlement to service connection for urinary problems as secondary to diabetes mellitus is denied. Entitlement to service connection for hip pain and bilateral leg cramps as secondary to diabetes mellitus is denied. Entitlement to service connection for tinnitus is denied. REMAND The matter of entitlement to service connection for a digestive disorder, to include diverticulitis, gastroesophageal reflux disease, duodenitis, and antral gastritis was last remanded in April 2011 for additional development of the evidentiary record. Unfortunately, the Board regretfully finds that the requested action was not sufficiently completed. Accordingly, another remand is mandatory. Stegall v. West, 11 Vet. App. 268 (1998). As detailed in the April 2011 remand, wherein the factual background of this issue is comprehensively reported, as part of a September 2010 VA examination report diagnoses of gastroesophageal reflux disease "per symptoms" and of diverticulosis "per imaging" were provided. The Board observed that the studies relied upon by the VA examiner were dated in 2005, almost six years old. As such, the Board found in April 2011 that "[c]urrent studies need to be performed in order to determine the accurate correct diagnoses." See page 15 of the April 2011 Board decision/remand. Development ordered as part of the Board's April 2011 remand was to include a VA examination and medical opinion. This examination is shown to have been conducted in July 2011. Review of this examination report shows that current studies were not preformed. The Board also finds that the opinions supplied by the VA examiner in July 2011 did not sufficiently address the posed questions set out by the Board in its July 2011 remand instructions. To this, the examiner was tasked with commenting on the complaints of heartburn and acid reflux made by the Veteran in September 1992, and opine as to the relationship, if any, to the November 1992 and December 1992 diagnoses of gastroesphageal reflux, duodenitis, antral gastritis, gastritis, hiatal hernia, and reflux esophagitis. Review of the esophagus and hiatal hernia examination report, as well as the report of stomach, duodenum and peritoneal adhesions shows that this requested opinion was not adequately supplied. Stegall. 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). On remand, the examiner should provide a more accurate opinion, one which is sufficiently responsive. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should schedule the Veteran for a VA digestive examination, by an appropriate specialist, to determine the nature and etiology of any currently present digestive disorder. The claims folder, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Current studies (i.e. imaging) and tests must be accomplished, and all clinical findings should be reported in detail. Based upon the claims folder review, the examination results and sound medical principles, the examiner should provide an opinion with respect to each currently present digestive disability as to whether it is at least as likely as not (ie., a 50 percent or better probability) that the disability is etiologically related to service. Attention is directed to the September 1991, April 1992, and September 1992 service treatment records, as well as the November 1992 and December 1992 post-service treatment records. Specifically, the examiner shall comment on the complaints of heartburn and acid reflux during service in September 1992, and the relationship, if any, of such to the November 1992 and December 1992 diagnoses of gastroesophageal reflux, duodenitis, antral gastritis, gastritis, hiatal hernia, and reflux esophagitis. The examiner should also comment on the Veteran's complaints of continuity of symptomatology. The examiner should set forth the complete rationale for all opinions expressed and conclusions reached. 2. The Veteran is hereby notified that it is his responsibility to report for any and all scheduled examinations and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for a scheduled examination, documentation should be obtained which shows that notice scheduling the examination was sent to the last known address. It should also be indicated whether any notice that was sent was returned as undeliverable. 3. To avoid a future remand, the RO/AMC should ensure that all requested development has been completed (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken before returning the case to the Board. See Stegall. 4. Following any other indicated development, the RO/AMC should readjudicate the appealed issue, in light of all the evidence of record. If the benefit sought on appeal remains denied, the Veteran and his representative should be provided a supplemental statement of the case (SSOC) that includes a summary of any additional evidence submitted, applicable laws and regulations, and the reasons for the decision. He should then be afforded an applicable time to respond thereto. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims remanded by the Board or by the Court 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). ______________________________________________ Alexandra P. Simpson Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs