Citation Nr: 1309190 Decision Date: 03/19/13 Archive Date: 04/01/13 DOCKET NO. 10-08 310A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida THE ISSUES 1. Entitlement to compensation benefits in accordance with the provisions of 38 U.S.C.A. § 1151 for Barrett's esophagus and reflux esophagitis, status post Nissen fundoplication (also claimed as nodules and polyps), claimed as additional disability resulting from 1987 VA treatment and surgery, including a July 1987 VA Nissen fundoplication. 2. Entitlement to an initial rating in excess of 10 percent for the service-connected posttraumatic stress disorder (PTSD). 3. Entitlement to a compensable initial rating for the service-connected residuals of a broken nose, to include septal deviation. 4. Whether new and material evidence has been received to reopen the claim of service connection for diabetes mellitus type II. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD S. Higgs, Counsel INTRODUCTION The Veteran had active service from July 1966 to June 1968. These matters are before the Board of Veterans' Appeals (Board) on appeal from RO rating decisions dated in August 2008 and January 2009. The Virtual VA paperless claims processing system contains recent VA records of treatment relevant to the severity of the service-connected PTSD and residuals of a broken nose, as well as ratings documentation indicating that the RO has awarded service connection for coronary artery disease and a total disability evaluation based on individual unemployability by reason of service-connected disability (TDIU). In June 2011 the Veteran submitted a Notice of Disagreement as to a May 2011 RO rating decision that continued the denial of the claim of service connection for diabetes mellitus type II. There is no indication in the claims file that the RO has issued a Statement of the Case as to this issue. In light of the present procedural posture of this claim, the Board is obligated to remand the issue for proper development, to include issuance of a Statement of the Case. See 38 U.S.C.A. § 7105 (filing of notice of disagreement and appeal); Manlincon v. West, 12 Vet. App. 238, 240-241 (1999). The other issues of an initial rating in excess of 10 percent for the service-connected PTSD, and a compensable rating for the service-connected residuals of a broken nose, to include septal deviation, also are being remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The Veteran is not shown to have additional disability due to VA treatment and surgery in 1987, including a July 1987 VA Nissen fundoplication. CONCLUSION OF LAW The criteria for the grant of compensation pursuant to the provisions of 38 U.S.C.A. § 1151 for Barrett's esophagus and reflux esophagitis, status post Nissen fundoplication (also claimed as nodules and polyps), claimed as additional disability due to VA treatment and surgery in 1987, including a July 1987 VA Nissen fundoplication, have not been met. 38 U.S.C.A. §§ 1151, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.361 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). A May 2008 VCAA letter explained the evidence necessary to substantiate the Veteran's claim for compensation for additional disability pursuant to 38 U.S.C.A. § 1151. This letter also informed the Veteran of his and VA's respective duties for obtaining evidence. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, the May 2008 letter from VA was provided prior to initial adjudication of the Veteran's claim and explained how a disability rating is determined and the basis for determining an effective date upon the grant of any benefit sought, in compliance with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The appellant has been provided with every opportunity to submit evidence and argument in support of his claim and to respond to VA notices. Further, the Board finds that the purpose behind the notice requirement has been satisfied because the appellant has been afforded a meaningful opportunity to participate effectively in the processing of his claim. With regard to the duty to assist, the claims file contains service treatment records, reports of VA post-service treatment, reports of private treatment, a report of a VA medical examination obtained at the RO, and a medical opinion from a Veterans Health Administration (VHA) medical specialist obtained by the Board. See 38 U.S.C.A. § 5103A(a)-(d) (duty to assist); 38 C.F.R. § 20.901(a) (opinion from the Veterans Health Administration may be obtained when in the Board's judgment medical expertise is needed for equitable disposition of an appeal). The VHA opinion was obtained in light of the complex nature of the VA surgery in July 1987. In the Board's view a medical expert was needed to assist in determining whether the surgery performed appropriately and was successful. The Board notes that the Veteran was recently awarded Social Security Administration (SSA) benefits, in July or August 2011, effective from July 2010. However, he has not indicated he wishes the Board to obtain the SSA records with respect to his claim pursuant to 38 U.S.C.A. § 1151. He has requested that VA review his SSA records in adjudication of his claims for increased rating for his service-connected disabilities, for service connection for ischemic heart disease, and for a TDIU rating. The claims for service connection for ischemic heart disease and a TDIU rating have since been granted. With respect to the claim pursuant to 38 U.S.C.A. § 1151, the Veteran indicated that he had no further evidence to submit, waived RO consideration of new argument and evidence received in February 2013, and desired the Board to immediately adjudicate his claim on appeal. Further, a form completed for SSA from an attending physician indicated that the Veteran was unemployable by reason of his ischemic heart disease, without reference to his gastroesophageal symptoms. Additionally, the time frame considered by SSA, from approximately the year 2010 forward, is not relevant to whether VA treatment and surgery in July 1987 resulted in additional disability to the Veteran. For these reasons, the Board finds that it need not remand the claim pursuant to 38 U.S.C.A. § 1151 for the purpose of obtaining the Veteran's SSA records; there is no reasonable possibility that obtaining such records would substantiate his claim and the Veteran has not claimed that obtaining the records is relevant to his claim pursuant to 38 U.S.C.A. § 1151. With respect to the VA opinions obtained in this matter, the Board notes that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As will be discussed, the Board requested a VHA medical opinion to supplement the medical evidence in the claims file. The VHA medical opinion obtained in January 2013 reflects a detailed review of the claims file, appropriate expertise on the part of the examiner, and thorough and well-reasoned explanations for the opinions rendered. As a result, the VHA physician's expert medical opinion report is of a highly probative weight and renders the medical evidence of record sufficient for the Board's consideration of the Veteran's claim on the merits. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to his claim. Essentially, all available evidence that could substantiate the claim for compensation pursuant to 38 U.S.C.A. § 1151 has been obtained. There is no indication in the claims file that there are additional available relevant records that have not yet been obtained. Law and Regulations The law provides that compensation may be paid for a qualifying additional disability not the result of the Veteran's willful misconduct, caused by hospital care, medical or surgical treatment, or examination furnished the Veteran when the proximate cause of the disability was: (A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or (B) an event not reasonably foreseeable. 38 U.S.C.A. § 1151. VA regulations provide that benefits under 38 U.S.C.A. § 1151(a) for claims received by VA on or after October 1, 1997, as in this case, for additional disability due to hospital care, medical or surgical treatment, or examination, require actual causation not the result of continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished, unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361. If additional disability is shown to exist, the next consideration is whether the causation requirements for a valid claim have been met. In order to establish actual causation, the evidence must show that the medical or surgical treatment rendered resulted in the Veteran's additional disability. See 38 C.F.R. § 3.361(c)(1). In addition, the proximate cause of the disability claimed must be the event that directly caused it, as distinguished from a remote contributing cause. 38 C.F.R. § 3.361(d). It must be shown that the hospital care, medical or surgical treatment, or examination caused the Veteran's additional disability, and that (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider or that (ii) VA furnished the hospital care, medical or surgical treatment, or examination without the informed consent of the Veteran or the Veteran's representative. To establish the proximate cause of an additional disability or death, it must be shown that there was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination, or that the additional disability was due to an event not reasonably foreseeable. Whether the proximate cause of a Veteran's additional disability or death was an event not recently foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. 38 C.F.R. § 3.361(d). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth at 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Merits of the Claim Upon review of the file, the Board notes that the claims file contains a substantial quantity of medical records. Although the Board has an obligation to provide adequate reasons and bases supporting its decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the issue on appeal. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). At the outset, the Board notes that the Veteran is competent to describe what he has personally experienced, including the symptoms he has experienced and the medications he has used. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Competency is a separate and distinct determination from credibility. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993). The Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board, however, may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App 171 (1991). The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993). The evidence shows that in January 1987 and February 1987, the Veteran sought treatment at VA for dysphagia on eating solids and the feeling of a lump in his throat. The problems were described as new over the past four months. He was diagnosed as having Barrett's esophagus. A February 1987 biopsy showed ulcerated, squamous mucosa with acute inflammation and granulation tissue and fragments of gastric-type mucosa with intestinal metaplasia consistent with Barrett's esophagus. The VA treatment records show that, in March 1987, the Veteran underwent a Maloney Dilation. A Maloney 34f passed easily. A 40f was apparently then used, and upon use of a 42f, according to the treatment record, the Veteran "gagged a lot and some heme [was] seen on dilation and spit up a small amount of blood. No pain." A May 1987 VA endoscopy showed severe reflux, with "no impediment at all"; Barrett's esophagus; esophageal polyp; and "no stricture now." The Veteran was admitted to a VA hospital for surgery on July 13, 1987, and underwent a Nissen fundoplication on July 17, 1987. He was discharged to home on July 24, 1987. The operative report, hospital discharge summary, and extensive in-patient treatment records are associated with the claims file. The follow-up VA treatment notes in September 1987 indicated that the Veteran had no reflux or dysphagia and was eating well. However, in February 1988 the Veteran sought VA treatment for recurring symptoms. An endoscopy in February 2008 showed antral erythema. The impressions were those of Barrett's esophagus, status post Nissen fundoplication, and antritis. A February 1988 VA biopsy showed gastric mucosa with intestinal metaplasia and chronic inflammation, and squamous mucosa with mild acute inflammatory exocytosis. A May 1988 treatment note indicated that the Veteran had a good response to the Nissen fundoplication, said that he would do it again and further that he still had some reflux. A November 1988 VA treatment report noted a Barrett's esophagus at 25 cm, described upon biopsy as intestinal metaplasia consistent with Barrett's esophagus, but not diagnostic. A December 1988 VA treatment record included an impression of esophageal reflux, status post Nissen fundoplication, fair control. A June 1998 VA hospital document entitled "Upper Endoscopy Instructions" showed that the Veteran had undergone an upper endoscopy and that the findings for the procedure included "no evidence of Nissen fundoplication." A June 1999 VA treatment record showed diagnoses of GERD and Barrett's esophagus secondary to GERD, with continuing symptoms and medication. Numerous VA treatment records in the claims file note that the Veteran's symptoms and Barrett's esophagus had persisted over the following years. A November 2007 report of a VA endoscopy sets forth findings of esophageal mucosal changes consistent with long-segment Barrett's esophagus, extending from the upper extent of the gastric folds that were at 35 cm from the incisors to the Z-line that was at 25 cm from the incisors. Circumferential salmon-colored mucosa was present from 25 to 35 cm. A VA medical opinion in this matter was obtained by the RO in November 2008. The November 2008 VA examination report is associated with the claims file. The examiner's opinion stated that the Veteran had a very severe non-medically responding large esophageal reflux with multiple episodes of esophagitis. The clinician opined that the post-op went fine, except for a small seroma that drained. The clinician elaborated that apparently the large reflux continued and that that the Veteran was noted to have Barrett's esophagus from at least the time of a 2003 endoscopy and biopsy at the VA Medical Center. It was noted that the aggressive medical positional treatments were provided for the Veteran's reflux and that his reflux was monitored by redo scopings in 2005 and 2007, with a repeat scheduled for 2010. The clinician asserted that he did not see a redo fundoplication having been done and that he did not see any additional disability related to the 1987 endoscopic fundoplication or the following Barrett's esophagus monitoring procedures. The examination report did indicate the reasons for the conclusions reached. As a result, the examination report is of very low probative value and weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (neither a VA examination report nor a private medical opinion is entitled to any weight in a service-connection or rating context if it contains only data and conclusions; most of the probative value of a medical opinion comes from its reasoning). At the request of the Board, a VHA medical expert opinion was obtained in January 2013. The VHA physician was as being board certified in gastroenterology. He expressed the view the Veteran did not experience any additional disability as the result of VA treatment in 1986 and 1987. After recounting the salient facts in this case, he reasoned as follows: In 1987 this veteran presented with symptoms of gastro-esophageal reflux disease (GERD or heartburn) and associated complications from heartburn demonstrated on upper endoscopy including ulceration, stricture and Barrett's esophagus. The patient was appropriately treated with acid suppression medication (H-2 blocker) and endoscopic stricture dilation. Given his complicated GERD, the patient underwent evaluation including manometry which demonstrated a zero pressure at the LES [lower esophageal sphincter] with normal peristalsis and after informed consent subsequent surgical management of his GERD in the form of Nissen Fundoplication. His post-operative course was uncomplicated and he was discharged at home with per notes 'having good response to surgery' in regards to his symptoms. The follow up at 1 year continued to demonstrate control of most of his heartburn symptoms and his satisfaction with the decision to proceed with surgery. [The VHA medical reviewer] felt that this veteran received the best possible care given the available medical and surgical literature in 1987 (see attached references). [He based] this opinion on the following: the patient had complicated GERD and long segment Barrett's on initial presentation, this was not uncommon in 1987, as acid suppression was not as commonly used as today and patients likely did not understand the medical significance of heartburn and thus presented to their physicians at a later stage of disease. The VA correctly proceeded with initial barium swallow examination and then upper endoscopy with biopsy, as was the recommendation at that time. The patient was correctly treated with acid suppression and appropriately underwent endoscopic dilation of a benign peptic stricture. The patient's physicians then recommended fundoplication in 1987. [He believed] this was based on the current medical opinion in 1987, including that surgery was effective in treating GERD and the low LES pressure suggested that perhaps the underlying cause of GERD was an lax LES which could be treated surgically, additionally data at that time suggested a much higher risk of progression to Barrett's associated esophageal cancer (reported as 10%). Potent acid suppression in the form of proton pump inhibitors (PPI) was not available in the United States and some conflicting data suggested that surgery [might] reduce this risk of cancer progression. Thus given the complicated GERD, low or zero pressure of LES, absence of available PPI and absence of randomized trials comparing surgery and H-2 blockers in 1987, [he felt] that his VA physicians appropriately treated this veteran to the best of their knowledge and ability. It is also to be noted that the surgery was uncomplicated and successful at least in the short term Thus [he found] no evidence that [sic] of carelessness, or negligence or fault with the VA treatment of GERD and Barrett's esophagus in 1986 and 1987. [He did not feel] that this veteran developed any additional disability due to this treatment. GERD and Barrett's esophagus was associated with a reduced quality of life. Medical research indicate[d] that 2 or more days per week of reflux symptoms [were] associated with a reduced quality of life. This veteran complained of occasional GERD symptoms and raspy voice in 2003 on high does acid suppression, but it [was] difficult to evaluate quality of life. Upper endoscopy in 2004 demonstrated his known long segment Barrett's without evidence of endoscopic erosions, likely indicating adequate acid suppression for erosive disease. Medical notes from 2005 indicate[d] that his heartburn [was] well controlled on twice a day omeprazole and once a day ranitidine. Notes from 2009 and 2010 mention occasional heartburn and a raspy voice managed with high dose acid suppression and life style modifications. He ha[d] received appropriate endoscopic surveillance for dysplasia. From the medical records it [was] possible that patient ha[d] a reduced quality of life from his heartburn symptoms, but [he felt] that his symptoms [had] been appropriately managed medically and given his significant co-morbidities it [was] difficult for me to find additional disability to this [V]eteran from his Barrett's esophagus. It is important to note that the latter paragraph of the VHA medical specialist, as set forth, addresses whether the Veteran has any additional disability due to current Barratt's esophagus, regardless of the cause; the first of the two paragraphs responds more directly to the specific medical question raised in this appeal-whether the Veteran had any additional disability due to VA treatment or surgery. The VHA specialist's reasoning indicates that, under the standard of care in the year 1987, the Veteran received VA care that was the best possible care given the available medical and surgical literature in 1987, consistent with the best practices at the time of the Veteran's treatment. The examiner found no carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination. Moreover, he found no additional disability due to the VA treatment and surgery at issue. The opinion is detailed and well explained. The examiner found that, under the very specific facts of this case, and under the protocol for care as it existed at that time, the outcome of the Veteran's 1987 VA treatment and July 1987 VA Nissen fundoplication resulted in no additional disability to the Veteran. The Board acknowledges the Veteran's lay-impressions as to the shortcomings of his care and why he feels he has experienced additional disability in the form of Barrett's esophagus and reflux esophagitis in light of what he perceives to be deficiencies in his VA Nissen fundoplication in July 1987. His recounting of events is generally credible; the Board notes that a May 1988 VA treatment note indicated that the Veteran had a good response to the Nissen fundoplication and that he said that he would do it again, but also noted that he still had some reflux. Insofar as it is noted in VA treatment records that the Veteran had symptoms that recurred within a year after the surgery, the Veteran's assertions are credible and are consistent with what is reflected in the medical records in the claims file, and in this regard are significant evidence of substantial probative value. The Board notes, however, that the VA records of treatment reflect an improvement in his condition after the surgery, to an extent such that the Veteran felt the surgery was worthwhile even after limited symptoms had recurred. Unlike the Veteran, the VHA medical specialist has the medical expertise to evaluate whether the Veteran experienced additional disability as a result of those aspects of the care that raise the Veteran's concerns. The Board finds the VHA specialist's opinion, based on a much higher level of medical understanding and knowledge of the standard of care appropriate for the Veteran's gastrointestinal symptoms at the time of the VA treatment and surgery in 1987, as compared to the lay-knowledge of the Veteran, is of a significantly greater probative value than the Veteran's lay-opinion that he now experiences additional disability as a result of perceived deficiencies in care provided him by VA in 1987. The Board finds the medical opinion of the January 2013 VHA medical specialist to be of a very high probative value and weight. The examination report reflects that the examiner took a detailed history, reviewed the claims file in detail, provided fully reasoned explanations for his opinions, referenced the standard of care appropriate for the time, providing supporting medical treatise and study evidence as it existed at the time of the treatment in question, and explained why the outcome of the treatment did not result in additional disability. The examiner displayed appropriate skill and expertise in the appropriate field of medicine and provided detailed explanations that were well-reasoned and consistent with the histories and medical evidence in the claims file. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (neither a VA examination report nor a private opinion is entitled to any weight if it contains only data and conclusions; most of the probative value of a medical opinion comes from its reasoning). Accordingly, the Board finds that the preponderance of the evidence demonstrates that the Veteran does not experience additional disability, manifested as Barrett's esophagus and reflux esophagitis, status post Nissen fundoplication (also claimed as nodules and polyps), for additional disability claimed as resulting from 1987 VA treatment including a July 1987 VA Nissen fundoplication. See 38 U.S.C.A. § 1151; 38 C.F.R. 3.361. As there is no additional disability shown, the Board need not reach the question of whether the proximate cause of any such additional disability was: (A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or (B) an event not recently foreseeable. Weighing the evidence of record, as detailed above, and after careful consideration of all procurable and assembled data, the Board finds that the preponderance of the evidence is against compensation under 38 U.S.C.A. § 1151 for additional disability due to VA treatment and surgery in 1987. As the preponderance of the evidence indicates that the Veteran does not experience additional disability due to the VA treatment and surgery afforded him, the benefit of the doubt rule is not for application in resolution of this appeal. Accordingly, on this record, the claim is denied. ORDER Entitlement to compensation benefits in accordance with the provisions of 38 U.S.C.A. § 1151 for Barrett's esophagus and reflux esophagitis, status post Nissen fundoplication (also claimed as nodules and polyps), claimed as additional disability resulting from VA treatment and surgery in 1987, including a July 1987 VA Nissen fundoplication, is denied. REMAND In October 2011 the Veteran requested that his SSA disability records be obtained in evaluating the severity of his service-connected disabilities. The evidence in the claims file indicates that the Veteran was recently awarded Social Security Administration (SSA) disability benefits, in July or August 2011, effective from July 2010. The records of the SSA should be obtained and associated with the claims file. See 38 U.S.C.A. § 5103A(a)-(c). The paper and Virtual VA claims files contain recent VA records of treatment relevant to the severity of the Veteran's PTSD and residuals of a broken nose. These records depict a greater degree of severity than that depicted at the most recent VA examinations for these disabilities in February 2010. A February 2012 VA treatment record includes a finding of chronic left-sided nasal congestion, and a May 2011 VA treatment record indicates a Global Assessment of Functioning score of 48 with respect to the Veteran's psychiatric disability, as opposed to a GAF score of 68 assigned at the February 2010 VA examination. Thus, the Veteran should be afforded a new VA examination with respect to these service-connected disabilities. See 38 C.F.R. §§ 3.326, 3.327 (reexaminations will be requested whenever VA determines there is a need to verify the current severity of a disability, such as when the evidence indicates there has been a material change in a disability or that the current rating may be incorrect); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95. Also, as there are indications in May 2011 VA psychiatric treatment records that the Veteran has an alcohol abuse disorder, the RO should request a medical opinion as to whether the alcohol abuse disorder is caused or chronically worsened by the Veteran's PTSD, or is a symptom of his PTSD. See 38 U.S.C.A. § 5103A(d). The law prohibits a grant of direct service connection for drug or alcohol abuse on the basis of incurrence or aggravation in the line of duty during service. Pub. L. No. 101-508, § 8052, 104 Stat. 1388, 1388- 351 (1990); VAOPGCPREC 2-98 (Feb. 10, 1998), 63 Fed. Reg. 31263 (1998). However, a Veteran may be service connected for an alcohol or drug abuse disability acquired as secondary to, or as a symptom of, his service-connected disability. Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001); see also Mittleider v. West, 11 Vet. App. 181 (1998) (where medical evidence shows that examiners are not able to distinguish the symptoms and/or degree of impairment due to a service-connected versus a nonservice-connected disorder, VA must consider all of the symptoms in the adjudication of the claim). Additionally, the Board notes that the above-referenced VA records of treatment have been received into the claims file since the most recent Supplemental Statement of the Case was issued as to these matters in September 2010. A new Supplemental Statement of the Case that includes consideration of this newly received evidence should be issued. See 38 C.F.R. § 19.31. On remand of these claims, the RO should seek to obtain any additional records of treatment with respect the Veteran's service-connected PTSD and residuals of a broken nose. See 38 U.S.C.A. § 5103A(a)-(c). Also, as noted above, in June 2011 the Veteran submitted a Notice of Disagreement with a May 2011 RO rating decision that continued the denial of a previously denied claim for service connection for diabetes mellitus type II. There is no indication in the claims file that the RO has issued a statement of the case as to this issue. In light of the present procedural posture of this claim, the Board is obligated to remand the issue for proper development, to include issuance of a Statement of the Case. See 38 U.S.C.A. § 7105 (filing of notice of disagreement and appeal); Manlincon v. West, 12 Vet. App. 238, 240-241 (1999). Accordingly, these remaining matters are REMANDED to the RO for the following action: 1. The RO should take all action, including issuance of a Statement of the Case, on the appeal initiated by the Veteran from the May 2011 rating decision addressing the issue of service connection for diabetes mellitus type II. The Veteran and his representative should be clearly advised of the need to file a timely Substantive Appeal if the Veteran wishes to complete an appeal from that determination. 2. The RO should also take appropriate steps to contact the Veteran in order to have him identify all relevant records of VA and non-VA health care providers who have treated him for the service-connected psychiatric disability or nose-related disability but that may not have been previously received into the claims file. After obtaining any appropriate authorizations for release of medical information, the RO should seek to obtain any potentially relevant and available records that have not been previously received from each health care provider the Veteran identifies. The records sought should include any additional potentially relevant records of VA treatment from October 2012 forward. The Veteran should also be advised that with respect to private medical evidence he may alternatively obtain the records on his own and submit them to the RO. 3. The RO also should take all indicated action to contact the Social Security Administration (SSA) in order to obtain and associate with the claims file copies of the Veteran's records regarding SSA benefits, including any SSA administrative decisions (favorable or unfavorable) and the medical records upon which the decisions were based. 4. Once all available relevant medical records have been received, the RO should make arrangements for the Veteran to be afforded a VA examination for the purpose of determining the current severity of his service-connected PTSD. The RO should send the claims file to the examiner for review, and the clinician should indicate that the claims file was reviewed. The examiner should indicate the nature and extent of the impact of the Veteran's service-connected psychiatric disability on his social and occupational functioning. The examiner should indicate whether the Veteran has an alcohol use disorder, and if so, whether it is caused by, chronically worsened by, or a symptom of his service-connected PTSD. The examiner should assign a Global Assessment of Functioning score, with a fully reasoned explanation for the score assigned. In all conclusions, the examiner should identify and explain the medical basis or bases, with identification of the relevant evidence of record. The examiner is requested to provide a fully reasoned explanation for his or her opinions, based on his or her clinical experience, medical expertise, and established medical principles. 5. Once all available relevant medical records have been received, the RO should make arrangements for the Veteran to be afforded a VA examination to determine the severity of his service-connected residuals of a broken nose. The RO should send the claims file to the examiner for review, and the clinician should indicate that the claims file was reviewed. The examiner should indicate whether the Veteran has any septal deviation. The examiner should indicate whether there is any disfigurement of the nose resulting from the Veteran's in-service nose injury. The examiner should provide an opinion as to whether the Veteran has either a 50-percent obstruction of both nasal passages or total obstruction of on one side. The examiner should indicate whether the Veteran's chronic left -sided nasal congestion, as indicated in a February 2012 VA treatment record, is due or chronically worsened by his service-connected residuals of a broken nose. In all conclusions, the examiner should identify and explain the medical basis or bases, with identification of the relevant evidence of record. The examiner is requested to provide a fully reasoned explanation for his or her opinions, based on his or her clinical experience, medical expertise, and established medical principles. 6. After completing all indicated development to the extent possible, the RO should readjudicate the claims remaining on appeal in light of all the evidence of record. If any benefit sought on appeal remains denied, the RO should furnish the Veteran and his representative with a fully responsive Supplemental Statement of the Case and they should be afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. No action is required of the Veteran until he is otherwise notified by the RO. By this action, the Board intimates no opinion, legal or factual, as to any ultimate disposition warranted in this case. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These matters 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). ______________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs