Citation Nr: 1310351 Decision Date: 03/27/13 Archive Date: 04/09/13 DOCKET NO. 07-27 198 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for a genitourinary disorder, to include urinary tract infections, erectile dysfunction, and urinary bladder dysfunction (claimed as cystitis). 2. Entitlement to service connection for a gastrointestinal disorder, to include gastritis and gastroenteritis. 3. Entitlement to service connection for chronic bronchitis, to include as due to asbestos exposure. 4. Entitlement to service connection for a disorder manifested by vision impairment, to include residuals of a left eye contusion. 5. Entitlement to a certificate of eligibility for specially adapted housing or a special home adaptation grant (SAH/SHA). REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD S. Dale, Counsel INTRODUCTION The Veteran served on active duty from October 1944 to June 1967. This matter comes before the Board of Veterans' Appeals (Board or BVA) on appeal from January 2006 and September 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, which denied the benefits sought on appeal. The Veteran appealed those decisions to the Board, and the case was referred to the Board for appellate review. The Board subsequently remanded the Veteran's claims for further development in September 2009 and July 2011. The Board's prior remand instructions and the actions of the RO and VA Appeals Management Center (AMC) will be discussed below. The Veteran's claims have been returned to the Board for further appellate proceedings. During the pendency of the Veteran's case, he also perfected to the Board appeals concerning claims to establish service connection for bilateral hearing loss and a right arm disability. In rating decisions dated in March 2011 and October 2012, the AMC granted service connection for these disabilities. The Veteran has not disagreed with the assigned evaluations or the effective dates. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second Notice of Disagreement must thereafter be timely filed to initiate appellate review of "downstream" issues such as the compensation level assigned for the disability or the effective date of service connection). Therefore, those matters have been resolved and are not in appellate status. The issue of entitlement to special monthly pension for aid and attendance or housebound status has been raised by the record. See a December 2011 statement from the Veteran. However, this claim has not been adjudicated by the Agency of Original Jurisdiction (AOJ), and thus, the Board does not have jurisdiction over it. Accordingly, that issue is REFERRED to the AOJ for appropriate action(s). Characterization of an issue on appeal In December 2004, the Veteran filed a claim to establish service connection for "prostate surgery." This claim was ultimately denied by the Board in the September 2009 decision. In June 2005, the Veteran filed a claim to establish service connection for "acute cystitis," which was initially denied by the RO in the January 2006 rating decision and is presently before the Board. As will be further discussed below, the Veteran's service treatment records reflect in-service treatment for acute cystitis; however, it does not appear that the Veteran has been diagnosed with cystitis since his separation from service. Rather, the medical evidence of record reflects post-service diagnoses of urinary tract infections, erectile dysfunction, benign prostate hypertrophy, and prostate cancer. The Veteran underwent a simple prostatectomy in March 1998. See e.g., the December 2012 VA examination report and a March 1998 private treatment record. Cystitis is "inflammation of the urinary bladder." DORLAND'S ILLUSTRATED MEDICAL DICTIONARY at pages 470-471 (31st ed. 2007). During the pendency of this appeal, the United States Court of Appeals for Veterans Claims (the Court) addressed the scope of a claim in regard to a claimed disability in Clemons v. Shinseki, 23 Vet. App. 1 (2009). In Clemons the Court held that, in determining the scope of a claim, the Board must consider the Veteran's description of the claim, symptoms described, and the information submitted or developed in support of the claim. Id. at 5. In light of the Court's decision in Clemons, the Board's final denial of the Veteran's claim to establish service connection for a prostate disorder in September 2009, and the evidence of record reflecting post-service symptomatology such as bladder neck obstruction as well as diagnoses of urinary tract infections, voiding dysfunction, and erectile dysfunction the Board has recharacterized the issue on appeal as stated on the title page. This will provide the most favorable review of the Veteran's claim in keeping with the Court's holding in Clemons. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issues of entitlement to service connection for chronic bronchitis, to include as due to asbestos exposure, entitlement to service connection for a disorder manifested by vision impairment, to include residuals of a left eye contusion, and entitlement to a certificate of eligibility for SAH/SHA, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC, in Washington, DC. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the Veteran's appeal has been obtained. 2. The Veteran's current genitourinary disorders, diagnosed as urinary tract infections, erectile dysfunction, and urinary bladder dysfunction, are not causally or etiologically related to active service. 3. The Veteran's current gastrointestinal disorders, diagnosed as gastritis, gastroenteritis, chronic constipation, and a duodenal polyp, are not causally or etiologically related to active service. CONCLUSIONS OF LAW 1. Service connection for a genitourinary disorder is not warranted. 38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 1131, 1154 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. Service connection for a gastrointestinal disorder is not warranted. 38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 1131, 1154 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (the VCAA) 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. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2010). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his/her representative, if applicable, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA 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. This notice must be provided prior to an initial unfavorable decision by the AOJ. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Further, in Dingess v. Nicholson, the Court held that, upon receipt of an application for a service-connection claim, VA is required to review the evidence presented with the claim and to provide the claimant with notice of what evidence not previously provided will help substantiate his/her claim. 19 Vet. App. 473 (2006); see also 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Specifically, VA must notify the claimant of what is required to establish service connection and that a disability rating and effective date for the award of benefits will be assigned if service connection is awarded. The Board finds that the VCAA duty to notify was satisfied by a letter sent to the Veteran in July 2005 with regard to the claims for service connection decided herein. The letter addressed all of the notice elements and was sent prior to the initial unfavorable decision by the RO in January 2006. The Board notes that the Veteran was not notified of how VA determines disability ratings and effective dates as per the Court's holding in Dingess at the time of the initial adjudication of his claims in January 2006. However, such was a practical and factual impossibility since the Court's decision in Dingess was not promulgated until March 2006 - two months after the January 2006 rating decision. However, a letter to the Veteran dated in May 2006 provided him with sufficient Dingess notification, and the Veteran's claims were subsequently readjudicated in an August 2006 rating decision and a subsequent statement of the case and several supplemental statements of the case. As such, there was not prejudice to the Veteran concerning the timing of these notice elements. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). VA has also satisfied its duty to assist the Veteran at every stage of this case with regard to the claim for right ear hearing loss. All available service treatment records as post-service VA and private treatment records are associated with the Veteran's claims file and Virtual VA file. Specifically, in September 2009, the Board directed that identified, pertinent VA and private were to be obtained and associated with the claims file. Review of the record reflects that this was subsequently accomplished by the AMC, and thus, the Board's September 2009 remand directives regarding obtaining outstanding medical evidence have been substantially complied with. Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). As will be further discussed below, there is an indication that the Veteran has received recent private treatment at Presbyterian Hospital in Matthews, North Carolina. See a VA treatment record dated in September 2012. However, neither the Veteran nor his representative has submitted a completed release so that VA may obtain these records or asserted that these records are pertinent to his claims to establish service connection for a gastrointestinal disorder or a genitourinary disorder. In the development of the Veteran's claims, VA has afforded the Veteran several VA examinations and obtained additional opinions. 38 C.F.R. § 3.159(c)(4). To that end, 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). Indeed, in the September 2009 and July 2011 remands, the Board directed that the Veteran was to be afforded additional VA examinations in connection with his claims because the examinations and opinions of record at those times were inadequate. The reports of the most recent VA examinations and opinions regarding the Veteran's claims decided herein, dated in December 2012, reflect that the VA clinician reviewed the Veteran's VA claims file and Virtual VA file and rendered diagnoses and medical opinions, accompanied with adequate rationale, which are consistent with the balance of the medical evidence of record. In light of above, the Board concludes that the December 2012 VA examination is adequate for the purpose of adjudicating the Veteran's claims decided herein, and thus, the Board's prior remand directives concerning affording the Veteran adequate VA examinations have been substantially complied with concerning these claims. Dyment and D'Aries, both supra. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination and opinions with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). VA has also assisted the Veteran and his representative throughout the course of this appeal by providing them with a statement of the case and supplemental statements of the case, which informed them of the laws and regulations relevant to his claims. For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110, 1131. In relevant part, 38 U.S.C. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability benefits. Generally, in order to establish direct service connection for a disorder, there must be (1) medical evidence of the current disability; (2) medical, or in certain circumstances, lay evidence of the in-service incurrence of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). However, medical evidence of a current disability and nexus is not always required to establish service connection. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition 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 v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (footnote omitted). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). If a chronic disease is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection if the disability is one that is listed in 38 C.F.R. § 3.309(a). The United States Federal Circuit Court recently held that the theory of continuity of symptomatology under 38 C.F.R. § 3.303(b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a), even if such is noted to be "chronic." See Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("Although interest may affect the credibility of testimony, it does not affect competency to testify."). Initial Notes The Board notes that the Veteran's extensive military career in the United States Navy includes service on several vessels between 1944 and 1967, to include being stationed aboard the USS SHARK, a nuclear submarine, from June 1963 to June 1966, while it was in the waters off-shore the Republic of Vietnam. The Board notes that the Veteran has not asserted that he was exposed to herbicides during his service, and he specifically denied setting foot in the Republic of Vietnam. See the September 2011 VA examination report. Accordingly, the laws and regulations pertinent to claims for service connection due to in-service exposure to herbicides need not be discussed. See 38 C.F.R. §§ 3.307(a)(6), 3.309(e); see also Haas v. Nicholson, 20 Vet. App. 257 (2006), rev'd sub nom. Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008). Further, as noted by the Board in the September 2009 decision, the Veteran's service records show that he was potentially exposed to radiation while working aboard nuclear vessels, and such exposure was tracked by the Navy. Claims to establish service connection based on exposure to ionizing radiation can be availed in three different ways. Ramey v. Brown, 9 Vet. App. 40, 44 (1996), affirmed at 120 F.3d. 1239 (Fed. Cir. 1997). First, there are certain types of cancer which will be presumptively service connected. 38 U.S.C.A. § 1112c; 38 C.F.R. § 3.309(d). Second, a list of "radiogenic diseases" recounted in 38 C.F.R. § 3.311(b)(2), (4) will be service connected provided that certain conditions specified in that regulation are met. The Board observes that the Veteran's claims decided herein do not involve any type of cancer listed in 38 C.F.R. § 3.309(d) or any "radiogenic disease" as defined in 38 C.F.R. § 3.311(b)(2), (4). While prostate cancer, a radiogenic disease listed in 38 C.F.R. § 3.311(b)(2), has been diagnosed, as noted above, the Veteran's claim to establish service connection for a prostate disorder was denied by the Board in the final September 2009 decision, and the claim presently on appeal does not include prostate cancer. The third way to establish service connection based on exposure to ionizing radiation is under 38 C.F.R. § 3.303(d) by showing that the disease was incurred during or aggravated by service without regard to the statutory presumptions - essentially, direct service connection. Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994); Stefl v. Nicholson, 21 Vet. App. 120 (2007). In light of above, the Board will focus the analysis of the Veteran's service connection claims on the theory of direct service connection, because it is the only etiological theory under which the Veteran's claim may prevail. Analysis Since the Veteran's claims involve application of similar facts to identical law, in the interest of economy, the Board will address them together. Concerning element (1), evidence of a current diagnosis, it is uncontroverted that, during the pendency of the appeal, the Veteran has been diagnosed with several gastrointestinal and genitourinary disorders, to include gastritis, status-post inguinal hernia, and chronic constipation, urinary tract infections, erectile dysfunction and urinary bladder dysfunction. See e.g., private treatment records dated in April 2008 and February 2010 as well as the December 2012 VA examination report. As such, element (1) has been demonstrated with respect to both claims. Regarding element (2), evidence of an in-service disease or injury, the Veteran's service treatment records are replete with instances of complaints of and treatment for symptomatology congruent with the claimed disorders. Specifically, treatment records dated in August 1960 reflect that the Veteran was admitted for treatment of acute urethritis and acute gastroenteritis of an undetermined cause. In June 1966, the Veteran was diagnosed with acute cystitis. In January 1967, he was treated for epigastric distress, and an ulcer was ruled out. In light of above, element (2) has been demonstrated for both claims. With respect to element (3), evidence of a nexus between the current disorders and an in-service injury or disease, the Board notes that the preponderance of the evidence of record is against the Veteran's claims. Concerning the Veteran's claim to establish service connection for a gastrointestinal disorder, the February 2010 VA examiner opined that there was no evidence to support a finding that the Veteran's chronic constipation and status-post inguinal hernia were related to his in-service treatment for gastritis or gastroenteritis. Because this opinion did not address all of the Veteran's post-service gastrointestinal disorders, the Board remanded the Veteran's claim for an adequate nexus opinion in July 2011. After a review of the Veteran's claims file, a VA clinician noted the Veteran's in-service treatment for acute gastroenteritis as well as his post-service treatment for gastrointestinal symptomatology and opined that, as there was no evidence of a chronic gastrointestinal disorder since the Veteran's acute episode in 1960, his currently diagnosed gastrointestinal disorders were less likely as not related to any incident of his service, to include the episode of acute gastroenteritis. See an October 2011 VA opinion. Thereafter, additional VA treatment records were associated with the Veteran's Virtual VA file, and thus, the AMC scheduled the Veteran for another VA examination to determine the nature and etiology of his current gastrointestinal disorders. After a review of the Veteran's claims file and Virtual VA file as well as an interview with and physical examination of the Veteran, the December 2012 VA examiner opined that the Veteran's post-service diagnoses of gastroenteritis/gastritis (which were noted to be acute in April 2008), duodenal polyp and chronic constipation were not caused or otherwise related to his in-service episode of gastroenteritis. In providing these opinions, the examiner observed that there was no evidence of chronicity or recurrence of gastrointestinal symptomatology between his in-service treatment and his most recent diagnoses. See the December 2012 VA examination report. With regard to the Veteran's claim to establish service connection for a genitourinary disorder, after a review of the claims file and an interview with and physical examination of the Veteran, the September 2011 VA examiner opined that the Veteran's voiding dysfunction was causally related to his prostate surgery rather than any incident of his service, to include in-service treatment of urinary tract infections and acute cystitis. In providing this opinion, the examiner noted that the Veteran had experienced voiding dysfunction since undergoing surgery for prostate cancer, and that such symptomatology is often a complication of this surgery. See the September 2011 VA examination report. After the additional VA treatment records were associated with the Veteran's Virtual VA file, he was afforded another VA examination in connection with his claim. After a review of the claims file and Virtual VA file as well as an interview with and physical examination of the Veteran, the December 2012 VA examiner opined that the Veteran's post-service urinary tract infections, bladder neck obstruction, erectile dysfunction, and voiding dysfunction were related to his treatment and surgery for prostate cancer rather than his service, to include his in-service urinary tract infections. In providing these opinions, the VA clinician noted the Veteran's post-service prostate surgery and maintenance of symptomatology, to include quarterly androgen deprivation therapy. See the December 2012 VA examination report. The only nexus evidence of record which is favorable to the Veteran's claims resonates from the Veteran. The Board acknowledges that competent medical evidence is not necessarily required where the determinative issue in a case involves medical causation or a medical diagnosis. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. Sept. 14, 2009), citing Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Barr v. Nicholson, 21 Vet App 303 (2007) (lay testimony is competent to establish the presence of varicose veins); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis). Here, the Veteran has consistently asserted that his current genitourinary and gastrointestinal disorders are related to his service, to specifically include his in-service treatment for gastritis/gastroenteritis, acute cystitis, and urinary tract infections. However, unlike the varicose veins in Barr or dislocated shoulder in Jandreau, a the Veteran's various gastrointestinal and genitourinary disorders are not a conditions that can be causally-related to military service without medical expertise. Davidson, 581 F.3d 1313; Buchanan, 451 F.3d 1331; Jandreau, 492 F.3d 1372. Thus, the Board concludes that, although the Veteran is competent to report symptoms, his statements as to the origin of his gastrointestinal and genitourinary disorders do not constitute competent evidence. As a layperson, he is not competent to provide evidence that requires medical knowledge because he lacks the requisite professional medical training, certification and expertise to present opinions regarding such matters. Furthermore, the Board finds that the VA examiners' etiological opinions are more persuasive than the Veteran's statements. The VA examiners conducted physical examinations of the Veteran, reviewed his entire record and medical history of the Veteran, and provided nexus opinions with a supporting rationale. Thus, the Board finds that the VA examiners' opinions are more persuasive than the statements of the Veteran with respect to the etiology of the Veteran's gastrointestinal and genitourinary disorders. As noted above, the Board acknowledges that service connection may be established on the basis of chronicity and/or continuity of symptomatology under 38 C.F.R. § 3.303(b). However, since none of the Veteran's current gastrointestinal or genitourinary disorders are listed among the disorders determined by VA to be "chronic" in 38 C.F.R. § 3.309(a), the provisions of 38 C.F.R. § 3.303(b) pertaining to chronicity and continuity of symptomatology are not for application in the present case. See Walker, supra. In light of the above, the Board finds that the preponderance of the evidence is against the Veteran's claims to establish service connection for gastrointestinal and genitourinary disorders. Because the preponderance of the evidence is against the Veteran's claims, the benefit of the doubt provision does not apply. Accordingly, the Board concludes that service connection for the claimed disorders is not warranted. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). ORDER Entitlement to service connection for a genitourinary disorder manifested by chronic infections of the urinary tract, erectile dysfunction, and urinary bladder dysfunction, is denied. Entitlement to service connection for a gastrointestinal disorder, to include gastritis and gastroenteritis, is denied. REMAND As noted above, the Board most recently remanded the Veteran's claims on appeal herein for further development in July 2011. Essentially, the Board concluded that further clarification was necessary concerning the nature and etiologies of the Veteran's asserted disorders. The Board directed that appropriate VA examinations be afforded to the Veteran in an effort to obtain clarifying diagnoses and opinions. After the AMC requested the development as directed by the Board, appropriate VA examinations were afforded to the Veteran in September 2011. At that time, the most recent VA treatment records associated with the Veteran's claims file were dated to July 2009. These VA examination reports and medical opinions are associated with the Veteran's claims file. In October 2012, the AMC requested updated VA treatment records. This request yielded updated electronic VA treatment records dated to September 2012 which were associated with the Veteran's Virtual VA file. In November 2012, the AMC requested that the Veteran be afforded additional VA examinations regarding his claims to establish service connection for a gastrointestinal disorder, a genitourinary disorder, and a disorder manifested by vision loss. It appears that these examinations were completed in December 2012. While the December 2012 VA examination reports pertaining to the Veteran's claims to establish service connection for a gastrointestinal disorder and a genitourinary disorder are associated with the claims file, the results of the December 2012 VA eye examination are not associated with the claims file or Virtual VA file. There is an indication that a VA eye examination took place, as the results of this examination, to include the examiner's opinions, are cited by the AMC in the December 2012 supplemental statement of the case. On remand, this examination report must be associated with the Veteran's VA claims file or Virtual VA file. Bell v. Derwinski, 2 Vet. App. 611 (1992) (holding that documents which were not actually before the adjudicators but had been generated by VA employees or submitted to VA by claimant were, "in contemplation of law, before the Secretary and the Board and should be included in the record"); Dunn v. West, 11 Vet. App. 462 (1998). Additionally, although the Veteran was afforded additional VA examinations concerning his vision, gastrointestinal, and genitourinary claims subsequent to the addition of updated VA treatment records to his Virtual VA file, he was not afforded another examination in connection with his claim to establish service connection for bronchitis. As such, this examiner was without the benefit of access the complete record. On remand, the Veteran must be afforded another VA examination in connection with this claim so that the nature and etiology of the Veteran's asserted bronchitis may be determined by an examiner who has had the benefit of reviewing all of the medical evidence of record. Also, as noted by the Board in the July 2011 remand, the Veteran's claim for SAH/SHA benefits is "inextricably intertwined" with the claims for service connection, and the disposition of the SAH/SHA claim must therefore be deferred pending resolving these preliminary matters. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). See also Parker v. Brown, 7 Vet. App. 116 (1994). However, any development necessary to properly adjudicate this claim, to include affording the Veteran a separate VA examination, must be undertaken if deemed necessary by the RO or AMC in light of the evidence obtained as a result of the Board's remand directives. As these claims are being remanded for other matters, the Board concludes that updated VA and private treatment records should be sought. A September 2012 VA treatment record reflects that the Veteran was, at that time, admitted to a private medical facility, Presbyterian Hospital, and his spouse and daughter were inquiring about options pertaining to private and/or VA nursing home care. The Board notes that the most recent private treatment records from Presbyterian Hospital associated with the claims file are dated in April 2011. Although there is no indication that these private records are pertinent to the Veteran's claims remanded herein, as they are being remanded for other matters, the Board concludes that these records should be sought if the Veteran submits a completed release for them. 38 U.S.C.A. § 5103A(c); 38 C.F.R. § 3.159(c)(1); see also Loving v. Nicholson, 19 Vet. App. 96, 102 (2005). Further, in light of the September 2012 VA treatment record alluding to the overall deterioration of the Veteran's health, possibly requiring long-term in-patient care, the Board concludes that updated VA treatment records should be obtained and associated with the claims file or Virtual VA file. Bell and Dunn, both supra. Further, the Veteran should be asked to identify any non-VA healthcare providers who have treated his for his disabilities on appeal herein. 38 U.S.C.A. § 5103A(c); 38 C.F.R. § 3.159(c)(1); Loving, supra. Therefore, in order to give the Veteran every consideration with respect to the present appeal and to ensure due process, it is the Board's opinion that further development of the case is necessary. Accordingly, the case is REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. The RO/AMC must contact the Veteran and request that he identify all non-VA health care providers that have treated him for his asserted chronic bronchitis, disorder manifested by loss in visual acuity, and/or disorders of the upper or lower extremities. The Board is particularly interested in any records from Presbyterian Hospital dated from April 14, 2011, to the present and any records regarding in-patient care at a private nursing home. The Veteran must complete a release for any private treatment records identified by him prior to any attempts to obtain such. All records obtained should be associated with the Veteran's VA claims file. If any requested records are not available, or if the search for any such records otherwise yields negative results, that fact should clearly be documented in the claims file, and the Veteran should be informed in writing. 2. The RO/AMC must obtain and associate with the claims file or Virtual VA file all outstanding records of VA treatment dated from September 7, 2012, to the present, to specifically include the report of the December 2012 VA eye examination. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact should clearly be documented in the claims file. 3. Thereafter, the Veteran's claims file and Virtual VA file should be made accessible to the clinician who performed the September 2011 VA examination and offered the medical opinion concerning the Veteran's bronchitis claim. After a review of all of the evidence of record, which must be noted on the examination report, the clinician is requested to, again, opine as to whether it is at least as likely as not (50 percent or greater probability) that any identified lower respiratory disorder, to include bronchitis, is etiologically related to service, taking into account all pertinent documented in-service medical history. The VA examiner is reminded of the need to provide a complete and thorough rationale for all conclusions reached. Provided that this clinician is unavailable, or is no longer employed by VA, schedule the Veteran for an appropriate examination by an examiner who has not seen him previously, and that addresses the inquiries set forth above regarding the disability claimed. 4. Thereafter, the Veteran's claims file and Virtual VA file should be made accessible to the clinician who performed the December 2012 VA eye examination and offered the medical opinion concerning the Veteran's vision loss. After a review of all of the evidence of record, which must be noted on the examination report, the clinician is requested to, again, opine as to whether it is at least as likely as not (50 percent or greater probability) that any identified disorder affecting the Veteran's vision is etiologically related to service, taking into account all pertinent documented in-service medical history. The VA examiner is reminded of the need to provide a complete and thorough rationale for all conclusions reached, to include with regard to the significance, if any, of a left eye contusion as the likely cause of current pathology. Provided that this clinician is unavailable, or is no longer employed by VA, schedule the Veteran for an appropriate examination by an examiner who has not seen him previously, and that addresses the inquiries set forth above regarding the disability claimed. 5. Thereafter, the RO/AMC should complete any development necessary for proper adjudication of the Veteran's claim to establish eligibility for SAH/SHA, to include scheduling the Veteran for an appropriate examination to obtain medical opinions. 6. Thereafter, the RO/AMC should then review the record. If any of the directives specified in this remand have not been implemented, appropriate corrective action should be undertaken before readjudication. Stegall v. West, 11 Vet. App. 268 (1998). 7. Thereafter, the RO/AMC should readjudicate the claims for service connection for bronchitis, a visual disability, and eligibility for SAH/SHA, based upon all additional evidence received. If any benefit sought on appeal is not granted, the Veteran and his representative should be furnished with a supplemental statement of the case and afforded an opportunity to respond before the file is returned to the Board for further appellate consideration. 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). No action is required of the Veteran until further notice. However, the Board takes this opportunity to advise the Veteran that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claims. His cooperation in VA's efforts to develop his claims, including reporting for any scheduled VA examination, is both critical and appreciated. The Veteran is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655. These claims 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). _________________________________________________ DENNIS F. CHIAPPETTA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs