Citation Nr: 1307367 Decision Date: 03/05/13 Archive Date: 03/11/13 DOCKET NO. 10-35 156 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in White River Junction, Vermont THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for varicose veins of the bilateral lower extremities, to include as secondary to residuals of left ankle fracture with traumatic arthritis. 2. Entitlement to service connection for varicose veins of the right lower extremity, to include as secondary to residuals of left ankle fracture with traumatic arthritis. 3. Entitlement to service connection for varicose veins of the left lower extremity, to include as secondary to residuals of right ankle fracture with traumatic arthritis. 4. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a back disability, to include as secondary to residuals of left ankle fracture with traumatic arthritis. 5. Entitlement to service connection for a back disability, to include as secondary to residuals of left ankle fracture with traumatic arthritis. 6. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a right knee disability, to include as secondary to residuals of left ankle fracture with traumatic arthritis. 7. Entitlement to service connection for a right knee disability, to include as secondary to residuals of left ankle fracture with traumatic arthritis. 8. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for left toe neuropathy, to include as secondary to residuals of left ankle fracture with traumatic arthritis. 9. Entitlement to service connection for left toe peripheral neuropathy, to include as secondary to residuals of left ankle fracture with traumatic arthritis. 10. Entitlement to service connection for left thigh nerve damage, to include as secondary to residuals of left ankle fracture with traumatic arthritis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Robert J. Burriesci, Counsel INTRODUCTION The Veteran served on active duty from February 1985 to January 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in White River Junction, Vermont. In September 2012, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of this hearing is associated with the claims folder. The issues of entitlement to service connection for varicose veins of the left lower extremity, to include as secondary to residuals of right ankle fracture with traumatic arthritis; entitlement to service connection for a back disability, to include as secondary to residuals of left ankle fracture with traumatic arthritis; entitlement to service connection for a right knee disability, to include as secondary to residuals of left ankle fracture with traumatic arthritis; entitlement to service connection for left toe peripheral neuropathy, to include as secondary to residuals of left ankle fracture with traumatic arthritis; and entitlement to service connection for left thigh nerve damage, to include as secondary to residuals of left ankle fracture with traumatic arthritis are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. In an August 2004 rating decision the RO denied service connection for varicose veins of the bilateral lower extremities, a back disability, a right knee disability, and left toe neuropathy. The Veteran was notified of this decision but did not perfect an appeal. 2. Evidence received subsequent to the August 2004 RO rating decision is neither cumulative nor redundant of evidence of record at the time of the prior denial, relates to unestablished facts necessary to substantiate the claims of service connection for varicose veins of the bilateral lower extremities, a back disability, a right knee disability, and left toe neuropathy, and raises a reasonable possibility of substantiating the claims. 3. The Veteran's varicose veins of the right lower extremity are due to his service-connected left ankle fracture with traumatic arthritis disability. CONCLUSIONS OF LAW 1. The RO's August 2004 rating decision denying service connection for varicose veins of the bilateral lower extremities, a back disability, a right knee disability, and left toe neuropathy is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.104(a), 3.160(d), 20.302(a), 20.1103 (2012). 2. Because evidence received since the August 2004 RO rating decision is new and material, the claims of service connection for varicose veins of the bilateral lower extremities, back disability, right knee disability, and left toe neuropathy, are reopened. 38 U.S.C.A. §§ 5107, 5108, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.156 (2012). 3. Varicose veins of the right lower extremity are causally related to the Veteran's service-connected left ankle fracture with traumatic arthritis disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the VA has a 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). In this case, the Board is reopening claims and granting in full the benefit sought on appeal in regard to varicose veins of the right lower extremity. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be further discussed. II. Applications to Reopen The Veteran is seeking to reopen his previously denied claims of entitlement to service connection for varicose veins of the bilateral lower extremities, a back disability, a right knee disability, and left toe neuropathy, all to include as secondary to residuals of left ankle fracture with traumatic arthritis. The claims for service connection for varicose veins of the bilateral lower extremities, a back disability, a right knee disability, and left toe neuropathy were previously denied in an August 2004 RO rating decision. The Veteran was notified of this decision in the same month but did not perfect an appeal. The evidence before VA at the time of the prior final decision consisted of the Veteran's service treatment records, private treatment records from Fletcher Allen, and reports of VA examinations dated in February 1987, April 1989, November 1999, and December 2003. The Board notes that the Veteran's service treatment records reveal that the Veteran complained of lower back pain in August 1986 and was diagnosed with lumbar back strain. Rating decisions are final and binding based on evidence on file at the time the claimant is notified of the decision and may not be revised on the same factual basis except by a duly constituted appellate authority. 38 C.F.R. § 3.104(a). The claimant has one year from notification of a RO decision to initiate an appeal by filing a notice of disagreement with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.160, 20.201, 20.302. If new and material evidence is received during an applicable appellate period following a RO decision (1 year for a rating decision and 60 days for a SOC) or prior to an appellate (Board) decision (if an appeal was timely filed), the new and material evidence will be considered as having been filed in connection with the pending claim that was pending at the beginning of the appeal period. See 38 C.F.R. § 3.156(b); Young v. Shinseki, 22 Vet. App. 461, 466 (2009). Further, except as otherwise provided, if at any time following issuance of a decision VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided a prior claim, VA will reconsider the claim. See 38 C.F.R. 3.156(c). The Board notes that it has the jurisdictional responsibility to determine on its own whether there is new and material evidence to properly reopen the service-connection claim. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001) (citing 38 U.S.C.A. §§ 5108, 7105(c)). See also Barnett v. Brown, 83 F. 3d 1380 (Fed. Cir. 1996) and VAOPGCPREC 05-92 (March 4, 1992). The Board acknowledges that additional treatment records were associated with the claims file within the year after the RO rating decision in August 2004. However, these records are not material because they do not associate the Veteran's claimed conditions with his active service or with his service-connected residuals of left ankle fracture with traumatic arthritis. In addition, as the Veteran to not file a timely notice of disagreement with the August 2004 RO rating decision, with regard to the issues of entitlement to service connection for varicose veins of the bilateral lower extremities, a back disability, a right knee disability, and left toe neuropathy, it is final. To reopen a claim that has been previously denied, new and material evidence must be submitted by or on behalf of a claimant. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). The provisions of 38 C.F.R. § 3.156(a) define "new" evidence as evidence not previously submitted to agency decision makers and "material" evidence as evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim(s) sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The provisions of 38 U.S.C.A. § 5108 require a review of all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened. See Evans v. Brown, 9 Vet. App. 273, 282-83 (1996). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. In determining whether evidence is new and material, the credibility of the new evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). The Veteran applied to reopen the claims of entitlement to service connection for varicose veins of the bilateral lower extremities, a back disability, a right knee disability, and left toe neuropathy at a hearing before a Decision Review Officer (DRO) in December 2006. Subsequent to the prior final denial in August 2004, in October 2010, May 2011, and August 2012 VA treatment notes indicate that the Veteran had varicose veins in a clump in the right mid calf. It was noted that it is reasonable to conclude that the Veteran's severe peripheral vascular disease (PVD) to the right mid calf are compensatory for his left ankle fracture history, as he must place his standing and walking weight onto his left side in compensation for lack of left ankle stability. In addition, in February 2007 a VA medical examiner provided an opinion regarding the etiology of the Veteran's claimed loss of sensation in his toes, low back pain, right knee, and varicose veins. The examiner indicated that it was impossible to identify any other conditions being due to or being aggravated by the Veteran's service-connected left ankle condition without resorting to speculation. At a hearing before the undersigned Veterans Law Judge in September 2012, the Veteran testified that his primary care physician has rendered the opinion that his varicose veins are caused by his service-connected left ankle. The Veteran further reported that while he was in a cast for his left ankle in service his low back hurt and that it has always been in pain due to a lack of stability in his ankles. He stated that his low back started to bother him approximately 10 years prior to the hearing but that he has not had any treatment for his low back pain. The Veteran reported that has had right knee pain for a long time and that as the years pass it has compounded; however, he stated that he does not receive any treatment for his right knee other than self medicating with Naproxen and rest. The Veteran reported that his left foot was numb and that he had the sensation for at least six, seven, or eight years. The Board finds that the treatment notes and the statements of the Veteran are new in that they were not associated with the claims file at the time of the prior final denial. In regard to whether the evidence is material, the Board notes that in order to warrant service connection for a left knee disorder the Veteran would have to show (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. 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). In the alternative, under 38 C.F.R. § 3.310, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board notes that under 38 U.S.C.A. § 5103A(d)(2), VA must provide a medical examination and/or obtain a medical opinion when there is: (1) competent evidence that the Veteran has a current disability (or persistent or recurrent symptoms of a disability); (2) evidence establishing that he suffered an event, injury or disease in service or has a disease or symptoms of a disease within a specified presumptive period; (3) an indication the current disability or symptoms may be associated with service; and (4) there is not sufficient medical evidence to make a decision. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board finds that the medical and lay statements are material in that they tend to show a relationship between the Veteran's claimed varicose veins of the bilateral lower extremities, back disability, right knee disability, and left toe neuropathy and his service-connected residuals of left ankle fracture with traumatic arthritis. The treatment notes dated in October 2010, May 2011, and August 2012 associate the Veteran's varicose veins of the right lower extremity with his service connected left ankle disability. The Veteran's statements at the hearing in September 2012 provide a more thorough description of his claimed conditions and are presumed credible for the purposes of reopening the claims. As such, considering the claims file as a whole, as the Veteran has provided evidence of varicose veins of the bilateral lower extremities, a back disability, a right knee disability, and left toe neuropathy, and has provided additional discussion regarding and association between these claims and his service-connected left ankle disability, the Board finds that the duty to provide the Veteran a VA medical examination has been triggered. Therefore, the claims of entitlement to service connection for varicose veins of the bilateral lower extremities, a back disability, a right knee disability, and left toe neuropathy are reopened. 38 C.F.R. § 3.156(a). III. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). As noted above, 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). Also noted above, under 38 C.F.R. § 3.310, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d at 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). The Veteran seeks entitlement to service connection for varicose veins of the right lower extremity. The Veteran contends that his varicose veins are proximately due to his service-connected residuals of left ankle fracture with traumatic arthritis. In December 2003 the Veteran was afforded a VA Compensation and Pension (C&P) examination. The examiner noted that the Veteran had varicose veins in the calf area of both legs, worse on the right. However, the examiner did not render an opinion regarding the etiology of these varicose veins. In February 2007, a VA medical examiner provided an opinion regarding the etiology of the Veteran's claimed loss of sensation in his toes, low back pain, right knee, and varicose veins. The examiner stated that: Without resorting to speculation it is impossible to identify any other conditions (i.e.: loss of sensation in toes, LBP, (R) knee, varicose veins and nerve damage (R) thigh as being due to or being aggravated by the service connected (L) ankle condition. As noted above, August 2004, October 2010, May 2011, and August 2012 VA treatment notes indicate that the Veteran had varicose veins in a clump in the right mid calf. It was noted that it is reasonable to conclude that the Veteran's severe peripheral vascular disease (PVD) to the right mid calf are compensatory for his left ankle fracture history, as he must place his standing and walking weight onto his left side in compensation for lack of left ankle stability. The Board finds that entitlement to service connection for varicose veins of the right lower extremity is warranted. The Veteran has been diagnosed with varicose veins of the right lower extremity. In addition, the Veteran is in receipt of service connected benefits for residuals of left ankle fracture with traumatic arthritis. It is observed that a VA medical opinion was obtained in February 2007 that indicates that the Veteran's varicose veins of the right lower extremity are not related to the Veteran's left ankle disability. However, this brief opinion lacks any rationale. Therefore, the Board finds that this opinion is of little probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Miller v. West, 11 Vet. App. 345, 348 (1998) ("A bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record."). In multiple VA treatment notes a VA provider rendered the opinion that the Veteran's varicose veins of the right lower extremity are related to his service-connected residuals of left ankle fracture with traumatic arthritis. In addition, these notes are accompanied by rationale. As such, the Board affords these treatment notes great probative weight. Therefore, as the Veteran is currently diagnosed with varicose veins of the right lower extremity, is in receipt of service-connected benefits for residuals of left ankle fracture with traumatic arthritis, and an opinion has been rendered associating his varicose veins of the right lower extremity with his residuals of left ankle fracture with traumatic arthritis, entitlement to service connection for varicose veins of the right lower extremity as secondary to his residuals of left ankle fracture with traumatic arthritis is granted. ORDER As new and material evidence has been received, the claim of entitlement to service connection for varicose veins of the bilateral lower extremities is reopened; to this extent only, the appeal is granted. As new and material evidence has been received, the claim of entitlement to service connection for a back disability is reopened; to this extent only, the appeal is granted. As new and material evidence has been received, the claim of entitlement to service connection for a right knee disability is reopened; to this extent only, the appeal is granted. As new and material evidence has been received, the claim of entitlement to service connection for left toe neuropathy is reopened; to this extent only, the appeal is granted. Service connection for varicose veins of the right lower extremity is granted. REMAND The Veteran seeks entitlement to service connection for varicose veins of the left lower extremity, a back disability, a right knee disability, left toe peripheral neuropathy, and left thigh nerve damage, all to include as secondary to residuals of left ankle fracture with traumatic arthritis. As noted above, in February 2007 a VA medical examiner provided an opinion regarding the etiology of the Veteran's claimed loss of sensation in his toes, low back pain, right knee, and varicose veins. The examiner indicated that it was impossible to identify any other conditions being due to or being aggravated by the Veteran's service-connected left ankle condition without resorting to speculation. The examiner provided no rationale for this opinion. Before relying on an examiner's conclusion that an etiology opinion would be speculative, the examiner must explain the basis for such an opinion or the basis must otherwise be apparent in the review of the evidence. See Jones v. Shinseki, 23 Vet. App. 382 (2010). In addition, the Board notes that the Court has held that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). As such, the Board finds this medical opinion inadequate. The Board notes that once VA undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). As such, the Board has no discretion and must remand the claims. The Board notes that the Veteran contends that he has left thigh nerve damage secondary to his service-connected left ankle disability. The Board acknowledges that the Veteran has reported that he does not receive treatment for his left thigh disability. However, the Veteran has competently reported that he has numbness in his left thigh and indicates that it is his belief this is related to his varicose veins and his left ankle disability. The Board notes that the Veteran has not been afforded a VA medical examination in regard to this issue. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a Veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the Veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C.A. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the Veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, as the Veteran has competently reported that he has numbness in his left thigh and is currently receiving service-connected benefits for a left ankle disability, the Board finds it necessary to afford the Veteran an examination regarding the etiology of his left thigh disability. Review of the claims file reveals that the Veteran received treatment in the Maple Leaf Farm Program. Records regarding this treatment have not been associated with the claims file. VA is required to make reasonable efforts to help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody. See 38 U.S.C.A. § 5103A(b)(1); 38 C.F.R. § 3.159(c)(1). As such, on remand, after obtaining adequate authorization, attempt to obtain and associate with the claims file all treatment records regarding the Veteran's varicose veins of the left lower extremity, back disability, knee, disability, left toe neuropathy, and left thigh disability from the Maple Leaf Farm Program. Review of the claims file reveals a notation that the Veteran received income from "pension, benefits or social security." It is unclear whether the Veteran in receipt of benefits from the Social Security Administration (SSA). Because SSA records are potentially relevant to the Board's determination, VA is obliged to attempt to obtain and consider those records. 38 U.S.C.A. § 5103A(c)(3); 38 C.F.R. § 3.159(c)(2); see Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010); Moore v. Shinseki, 555 F.3d 1369 (Fed. Cir. 2009). Therefore, on remand attempts must be made to obtain any SSA records regarding the Veteran. Since the claims file is being returned it should be updated to include VA treatment records regarding the Veteran compiled since September 2012, including those from the VA Medical Center in White River Junction, Vermont, and the VA Outpatient Clinic at Fort Ethan Allen. See 38 C.F.R. § 3.159(c)(2); see also Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. Attempt to obtain VA medical records pertaining to the Veteran that are dated since September 2012, including those from the VA Medical Center in White River Junction, Vermont, and the VA Outpatient Clinic at Fort Ethan Allen. 2. Request, directly from the SSA, complete copies of any determination on a claim for disability benefits from that agency, together with the medical records that served as the basis for any such determination. All attempts to fulfill this development should be documented in the claims file. If the search for these records is negative, that should be noted and the Veteran must be informed in writing. 3. After securing the proper authorization, request treatment records regarding the Veteran and pertaining to his varicose veins of the left lower extremity, back disability, knee, disability, left toe neuropathy, and left thigh disability from the Maple Leaf Farm Program. Any additional pertinent records identified by the Veteran during the course of the remand should also be obtained, following the receipt of any necessary authorizations from the Veteran, and associated with the claims file. 4. Thereafter, schedule the Veteran for VA examination(s) to ascertain the etiology of any varicose veins of the left lower extremity, back disability, right knee disability, left toe peripheral neuropathy, and left thigh nerve damage found to be present. The claims file and a copy of this remand must be made available to the examiner for review in conjunction with the examination. All indicated testing should be conducted. The examiner(s) must specifically review and comment on the February 2007 VA medical opinion and the reports of the Veteran. After a review of the examination findings and the entire evidence of record, the examiner(s) must answer the following question: Is it at least as likely as not (50 percent or greater probability) that any varicose veins of the left lower extremity, back disability, right knee disability, left toe peripheral neuropathy, and left thigh nerve damage found to be present is related to or had its onset during service? Is it at least as likely as not (50 percent or greater probability) that any varicose veins of the left lower extremity, back disability, right knee disability, left toe peripheral neuropathy, and left thigh nerve damage found to be present is proximately due to or permanently aggravated by the Veteran's service-connected left ankle disability? The examiner(s) are advised that the term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of the medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. More likely and as likely support the contended causal relationship or a finding of aggravation; less likely weighs against the claim. The examiner is also advised that aggravation is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms. A complete rationale for all opinions expressed must be provided. 5. After completion of the above and any other development deemed necessary, review and re-adjudicate the issue on appeal. If such action does not grant the benefit claimed, provide the Veteran and his representative a supplemental statement of the case and an appropriate period of time should be allowed for response. Thereafter, the case should be returned to this Board for appellate review. 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