Citation Nr: 1308459 Decision Date: 03/13/13 Archive Date: 03/20/13 DOCKET NO. 09-04 930 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for diabetes mellitus claimed as elevated blood sugar readings. 2. Entitlement to service connection for bilateral defective hearing. 3. Entitlement to service connection for an inner ear disorder. 4. Entitlement to service connection for disorders of the legs and hands to include degenerative joint disease of the legs and hands. 5. Entitlement to an initial evaluation for gynecomastia, status post subcutaneous mastectomy with residual scar, currently evaluated as 30 percent disabling. 6. Entitlement to an initial evaluation for degenerative joint disease of the left shoulder, currently evaluated as 10 percent disabling. 7. Entitlement to an initial evaluation for degenerative disc disease of the lumbar spine with compression fracture of the thoracic spine, currently evaluated as 10 percent disabling. 8. Entitlement to a compensable initial evaluation for degenerative joint disease of the right great toe. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Nadine W. Benjamin, Counsel INTRODUCTION The Veteran served on active duty from November 1964 to October 1969, and from October 1977 to November 2003. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The Veteran's representative stated that the issues of entitlement to service connection for hepatitis and for lipidosis were claimed in 2003 but were not addressed by the rating decision dated in January 2004. However, upon review of the evidence of record, the Board finds that entitlement to service connection for coronary artery disease, claimed as atherosclerotic heart disease and lipidosis was granted by the January 2004 rating decision. The issue of entitlement to abnormal liver studies and hepatitis was denied by the RO in January 2004, but was not appealed. Therefore, the Board does not have jurisdiction over these issues. Although not certified on appeal by the RO, the Board finds that the issues of entitlement to service connection for degenerative joint disease of the lower extremities and degenerative joint disease of the upper extremities, as well as entitlement to an initial compensable evaluation for the right great toe replacement, status post degenerative joint disease, are within the Board's jurisdiction. These issues were denied by a December 2011 rating decision, and the Veteran initiated an appeal as to these issues in a notice of disagreement dated in April 2012. 38 C.F.R. § 20.201 (2012). A statement of the case with regard to these issues was issued in June 2012, and by a statement from the representative of the Veteran received in November 2012, the Board finds that the appeal as to these issues was perfected. 38 C.F.R. § 20.202 (2012). The issues of entitlement to higher initial evaluations for degenerative joint disease of the left shoulder, degenerative disc disease of the lumbar spine with compression fracture of the thoracic spine, and degenerative joint disease of the right great toe, as well as entitlement to service connection for diabetes mellitus and for degenerative joint disease of the upper and lower extremities are remanded the RO via the Appeals Management Center in Washington, DC. FINDINGS OF FACT 1. In November 2012, prior to the promulgation of a decision in the appeal, the Veteran withdrew his appeal as to the issue of entitlement to an initial evaluation higher than 30 percent for gynecomastia, status post subcutaneous mastectomy with residual scar. 2. A current diagnosis of an inner ear disorder is not of record. 3. The evidence of record does not demonstrate a current diagnosis of a bilateral hearing loss disability for VA compensation purposes. CONCLUSIONS OF LAW 1. The criteria have been met for withdrawal of the substantive appeal by the Veteran for the issue of entitlement to an initial evaluation higher than 30 percent for gynecomastia, status post subcutaneous mastectomy with residual scar. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2012). 2. The criteria for service connection for an inner ear disorder have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2012). 3. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Proper notice from VA must inform the Veteran of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the Veteran is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements apply to all five elements of a service connection claim, including: (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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. The RO's August 2003 letter advised the Veteran of the foregoing elements of the notice requirements. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); see also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The letter did not provide the Veteran with notice of what type of information and evidence was needed to establish disability ratings, as well as notice of the type of evidence necessary to establish an effective date. See Dingess/Hartman, 19 Vet. App. at 486. However, there is no prejudice in issuing a final decision because the preponderance of the evidence is against the claims for service connection decided below. Any questions as to the appropriate disability rating or effective date to be assigned are moot. Moreover, 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 claim, including the opportunity to present pertinent evidence. The duty to assist the Veteran has been satisfied in this case. The RO has obtained the Veteran's service treatment records and his identified VA and private treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. He was provided a hearing before the Board in November 2012, at which time he was informed of the evidence needed to support his claim and questioned about any possible evidence that may have been overlooked. 38 C.F.R. § 3.103 (2012). Moreover, the Veteran has been afforded VA examinations that are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Specifically, the September 2003 and the April 2012 examiners reviewed the record, considered the Veteran's statements and treatment records, and provided audiometric testing, as well as a clinical examination. No opinion was offered as the claimed disorders were not diagnosed. While the Veteran questioned the adequacy of the examinations, based on the above, the Board finds the testing provided was adequate to make a determination. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess, 19 Vet. App. at 486; see also Shinseki v. Sanders, 129 S. Ct. 1696 (2009). I. Gynecomastia By a January 2004 rating decision, the RO granted service connection for gynecomastia, status post subcutaneous mastectomy with residual scar, and assigned a noncompensable evaluation, effective from December 2003. The Veteran disagreed with that determination and this appeal ensued. In June 2012, the RO granted a 30 percent evaluation for gynecomastia, status post subcutaneous mastectomy with residual scar, effective from December 2003. During his Board hearing in November 2012, the Veteran stated that he wished to withdraw his appeal as to the issue of entitlement to gynecomastia, status post subcutaneous mastectomy with residual scar. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105. A substantive appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. §§ 20.202, 20.204. With regard to this issue, prior to the promulgation of a decision by the Board, the Veteran indicated that he wished to withdraw his appeal. As a result, no allegation of error of fact or law remains before the Board for consideration with regard to the issue of entitlement to an initial evaluation higher than 30 percent for gynecomastia, status post subcutaneous mastectomy with residual scar. As such, the Board finds that the Veteran has withdrawn his claim as to this issue, and accordingly, the Board does not have jurisdiction to review the appeal as to the issue of entitlement to an initial evaluation higher than 30 percent for gynecomastia, status post subcutaneous mastectomy with residual scar and it is dismissed. II. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection for certain chronic diseases, to include sensorineural hearing loss, will be presumed if they are manifest to a compensable degree within the year after active service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503, 505 (1992). Generally, in order to establish service connection for a claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). A. Inner Ear Disorder The service treatment records show that the Veteran was treated in service in April 1969 for an earache; the diagnosis was otitis media. At service separation in July 1969, examination of his ears was normal. In a report of medical history, it was noted that the Veteran had a history of his ear bleeding on the firing range. However, on that examination, a perforation was not seen. In May 2003, it was noted that the Veteran had bleeding from the ear drum. Thereafter, in July 2003, cochlear inner ear damage was noted. However, an magnetic resonance imaging scan that month showed the inner ear was normal. On preservice discharge examination in September 2003, the Veteran denied any aural fullness, pain, drainage, and history of ear surgery. While the Veteran had inservice complaints, there is no current diagnosis of an inner ear disorder. A VA examination in April 2012 showed no inner ear problem and private records in the file are also negative for an inner ear problem. The Veteran complained of right ear pain on private treatment in April 2008, but no diagnosis was entered. "Pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted." Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Lay evidence can be competent and sufficient to establish a diagnosis of a disorder when (1) a 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. Jandreau, 492 F.3d at 1377; see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2007). While the Veteran's statements are competent evidence as to the pain he experiences, they are not competent evidence to provide a diagnosis with respect to whether he has a diagnosed disability related to the inner ear. Id. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that the requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In the absence of proof of a present disability, there can be no valid claim. Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Without evidence of a current disability at any time during the appeal period, the preponderance of the evidence is against the Veteran's claim for service connection for an inner ear disorder. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). No further discussion of the two remaining elements of a service connection claim is necessary. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). As the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply, and service connection for an inner ear disorder is not warranted. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). B. Bilateral Hearing Loss Impaired hearing will be considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran's service treatment records show that on the entrance during his first period of service in October 1964, a hearing disability for VA purposes was not shown. The authorized audiological evaluation revealed pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -10 (5) -10 (0) -10 (0) 0 (5) LEFT -10 (5) -10 (0) 0 (10) 0 (5) Note: The January 1964 audiometric test results were reported in standards set forth by the American Standards Association (ASA). The ASA results are the figures on the left of each column and are not in parentheses. Since November 1, 1967, those standards have been set by the International Standards Organization (ISO)-American National Standards Institute (ANSI). In order to facilitate data comparison, the ASA standards have been converted to ISO-ANSI standards and are represented by the figures in parentheses.). Although a decrease in hearing acuity at separation in July 1969 was found, a hearing disability for VA purposes was not shown. The authorized audiological evaluation revealed pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 10 10 15 10 LEFT 15 10 20 20 20 On a May 1982 periodic examination, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 5 15 15 LEFT 10 10 10 15 10 On annual examination in August 1986, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 5 10 15 LEFT 5 5 5 10 5 In July 1991, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 5 15 10 LEFT 5 10 10 10 5 In May 2003, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 20 20 10 LEFT 15 20 25 25 20 The Veteran reported having good hearing and noise exposure on the firing range. The finding was noted as normal hearing sensitivity, right ear, except a slight hearing loss at 8000 Hertz, and left ear normal to slight from 250-8000 Hertz. In June 2003, mild hearing loss was noted in both ears. No audiometric findings were documented. In a July 2003, a post service military examiner indicated that an audiogram showed hearing loss, secondary to noise and cochlear inner ear damage. However, the examiner indicated that a magnetic resonance imaging scan was normal. When the Veteran underwent a pre-discharge examination in September 2003, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 10 20 10 LEFT 15 10 20 25 15 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 98 percent in the left ear. Mild sensorineural hearing loss was noted at 8000 Hertz on the right, and 6000 to 8000 Hertz on the left. The diagnosis was hearing threshold levels that did "not meet the criteria for disability, per VA regulatory definition, bilaterally." Although a hearing disability is not shown in service, service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d); Cosman, 3 Vet. App. at 505; see also Hensley v. Brown, 5 Vet. App. 155 (1993) (holding that if a hearing loss disability as defined by 38 C.F.R. § 3.385 is not shown in service or at separation from service, service connection can be established if medical evidence shows that it is actually due to incidents during service). Subsequent to service discharge, on VA examination in April 2012, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 25 30 30 LEFT 20 20 25 30 25 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 96 percent in the left ear. Accordingly, a current hearing loss disability for VA benefit purposes, has not been shown by the medical evidence of record. As noted above, entitlement to service connection for VA benefits are limited to cases where there is a current disability shown during the appeal period. Brammer, 3 Vet. App. at 225; see also McClain, 21 Vet. App. at 321. Absent medical evidence reflecting the current presence of the claimed disability, a basis upon which to establish service connection for a bilateral hearing loss disability has not been presented. To the extent that the Veteran asserts that he currently has a bilateral hearing loss disability, his statements are not competent evidence as to whether his hearing acuity rises to the level of a disability for VA purposes, as the evidence of record does not demonstrate that the Veteran possesses the ability, knowledge, or experience to provide competent diagnostic opinions. Jandreau, 492 F.3d at 1377. As a current bilateral hearing loss disability for VA compensation purposes has not been shown, the preponderance of the evidence is against this service connection claim. See 38 C.F.R. § 3.385. No further discussion of the two remaining elements of a service connection claim is necessary. As such, the benefit-of-the-doubt rule does not apply and service connection for a bilateral hearing loss disability is not warranted. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 53. ORDER The claim for an initial evaluation for gynecomastia, status post subcutaneous mastectomy with residual scar, currently evaluated as 30 percent disabling, is dismissed. Service connection for an inner ear disorder is denied. Service connection for a bilateral hearing loss disability is denied. REMAND Increased Ratings The Veteran was last examined regarding his service-connected disorders in April 2005, approximately eight years ago. The duty to assist includes providing a thorough and contemporaneous examination. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). Thus the Veteran must be scheduled for a VA disability evaluation examination to determine the current status of his service-connected degenerative joint disease of the left shoulder, degenerative disc disease of the lumbar spine with compression fracture of the thoracic spine, and degenerative joint disease of the right great toe. Service Connection Diabetes Mellitus The evidence shows that the Veteran had elevated blood glucose readings during service and shortly thereafter. For example, in March 2003, the blood glucose reading was 115 and documented on the blood test as high. In February 2004, the blood glucose reading was 111 and noted as high. However, the service treatment records do not reflect any diagnosis of, or treatment for, diabetes. Post service, impaired fasting glucose was noted in December 2006. In January 2007, the Veteran was told he was pre-diabetic, and given instructions on a diabetic diet. In March 2007, diabetes mellitus was diagnosed. Given the Veteran's elevated blood glucose readings during service and shortly thereafter, the Board finds that an opinion as to whether the Veteran's current diabetes mellitus, type II, is related to his military service is needed. Degenerative Joint Disease Of The Upper and Lower Extremities The Veteran claims that he has disorders of the legs and hands, including arthritis, that are related to service. The Veteran contends that he has had arthritis since military service. Service treatment records show that the Veteran was treated for left hand numbness in November 1991, left hand weakness in January 1992, forearm parathesias in March 1992, and a wound to the left calf in 2000. Current diagnoses of right hand problems, right wrist problems, knee arthritis, carpal tunnel syndrome, and arthritis are of record. Accordingly, the case is remanded for the following action: 1. The RO must contact the Veteran and afford him the opportunity to identify or submit any additional VA or non-VA pertinent evidence in support of his claims. Based on his response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. All attempts to secure this evidence must be documented in the claims file by the RO. If, after making reasonable efforts to obtain named records the RO is unable to secure same, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that he is ultimately responsible for providing the evidence. The Veteran and his representative must then be given an opportunity to respond. 2. The Veteran must be afforded the appropriate VA examination to determine the current severity of his service-connected degenerative joint disease of the left shoulder; degenerative disc disease of the lumbar spine, with compression fracture of the thoracic spine; and degenerative joint disease of the right great toe. The claims file and all records on Virtual VA must be made available to the examiner, and the examiner must specify in the examination report that the claims file and Virtual VA records have been reviewed. The examiner must specify the dates encompassed by the Virtual VA records that were reviewed. Any indicated diagnostic tests and studies must be accomplished. As to the degenerative joint disease of the left shoulder; degenerative disc disease of the lumbar spine, with compression fracture of the thoracic spine; and degenerative joint disease of the right great toe, all pertinent symptomatology and findings should be reported in detail. As to the left shoulder, the examiner must provide the range of motion in degrees using a goniometer. The examiner must note if there is nonunion, dislocation, guarding, motion limited to shoulder level, midway between the side and the shoulder, motion limited to 25 degrees from the side, or favorable or unfavorable abduction. As to the lumbar spine, range of motion must be provided in degrees using a goniometer, and the examiner must note if there is guarding, muscle spasm, abnormal gait, or abnormal spinal contour. If there is clinical evidence of pain on motion, the examiner must indicate the specific degree of motion at which such pain begins. The same range of motion studies must then be repeated after at least three repetitions and after any appropriate weight-bearing exertion. Then, after reviewing the Veteran's complaints and medical history, the examiner must render an opinion as to the extent to which the Veteran experiences functional impairments, such as weakness, excess fatigability, lack of coordination, or pain due to repeated use or flare-ups. Objective evidence of loss of functional use can include the presence or absence of muscle atrophy and/or the presence or absence of changes in the skin indicative of disuse due to the service-connected left shoulder or the service-connected back disorder. The examiner must note any associated neurological findings. As to the right great toe disorder, the examiner must determine if the disorder is severe or equivalent to amputation of the great toe, or if there is resection of the metatarsal head. A complete rationale for all opinions must be provided. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of a particular examiner. The report prepared must be typed. 3. The Veteran must be afforded a VA examination to determine whether the currently diagnosed diabetes mellitus, type II, is related to his military service. All pertinent symptomatology must be reported in detail. Any diagnostic tests and studies must be accomplished. The claims file and all records on Virtual VA must be made available to the examiner, and the examiner must specify in the examination report that the claims file and Virtual VA records have been reviewed. The examiner must specify the dates encompassed by the Virtual VA records that were reviewed. Based on the clinical examination, a review of the evidence of record, and with consideration of the Veteran's statements, the examiner must state whether diabetes mellitus, type II, is related to the Veteran's military service. A complete rationale for all opinions must be provided. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of a particular examiner. The report prepared must be typed. 4. The Veteran must be afforded a VA examination to determine whether any upper or lower extremity disorder found is related to his military service. All pertinent symptomatology must be reported in detail. Any diagnostic tests and studies must be accomplished. The claims file and all records on Virtual VA must be made available to the examiner, and the examiner must specify in the examination report that the claims file and Virtual VA records have been reviewed. The examiner must specify the dates encompassed by the Virtual VA records that were reviewed. Based on the clinical examination, a review of the evidence of record, and with consideration of the Veteran's statements, the examiner must state whether upper and lower extremity disorder found is related to the Veteran's military service. A complete rationale for all opinions must be provided. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of a particular examiner. The report prepared must be typed. 5. The RO must notify the Veteran that it is his responsibility to report for 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 must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 6. After the development requested has been completed, the RO must review the examination reports to ensure that they are in complete compliance with the directives of this remand. If a report is deficient in any manner, the RO must implement corrective procedures at once. 7. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken above, the claims on appeal must be readjudicated. If any benefit on appeal remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs