Citation Nr: 1312432 Decision Date: 04/15/13 Archive Date: 05/02/13 DOCKET NO. 06-30 139 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to service connection for diabetes mellitus, to include as secondary to herbicide exposure. 2. Entitlement to service connection for a cardiovascular disability, to include as secondary to herbicide exposure, diabetes mellitus, or posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD Carole Kammel, Counsel INTRODUCTION The Veteran served on active duty in the United States Navy from May 1969 to December 1970. These matters are before the Board of Veterans' Appeals (Board) on appeal from a November 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa that denied service connection for diabetes mellitus and a cardiovascular disability. This appeal was most recently before the Board in September 2011. At that time, the Board, in part, remanded the service connection issues on appeal to the RO for additional substantive development. The issues have returned to the Board for appellate consideration. After the September 2011 remand and prior to the appeal's recertification to the Board in February 2013, the RO, in a November 2011 rating decision, granted service connection for ischemic heart disease and diabetes mellitus type, 2, each secondary to herbicide exposure. The RO assigned initial 10 and 20 percent disability ratings, effective March 24, 2004 and February 25, 2004, the dates VA received the Veteran's initial claims for compensation for those disabilities. In a September 2012 rating action, the RO proposed to sever service connection for ischemic heart disease and diabetes mellitus. A September 2012 letter from the RO informed the Veteran of its proposal to sever service connection for ischemic heart disease and diabetes mellitus. The RO notified the Veteran of his right to request a hearing on his claims after 30 days of issuance of the September 2012 letter. In a November 2012 rating action, the RO severed service connection for ischemic heart disease and diabetes mellitus. The RO based its decision on a lack of evidence documenting that the Veteran had in-county service in the Republic of Vietnam. The Veteran was informed of the RO's decision in a November 2012 letter. He was provided notice of his appellate rights. The Veteran did not appeal the November 2012 rating action. Thus, the severance of service connection for ischemic heart disease and diabetes mellitus is not in dispute and the issues have returned to the Board in their original posture as claims for service connection. The issue of entitlement to a cardiovascular disability is REMANDED to the RO via the Appeals Management Center in Washington, D.C. FINDINGS OF FACT 1. The Veteran had no confirmed service in the Republic of Vietnam during the Vietnam Era; and, although the Veteran served on a United States Naval ship, USS Advance, off the coasts of Vietnam, he had no confirmed exposure to herbicides during his active military service. 2. There is no competent and credible evidence the Veteran's diabetes mellitus, had its onset in service or within a year of service discharge, or that any current diabetes mellitus, is related to his active military service, including exposure to herbicides. CONCLUSION OF LAW Diabetes mellitus was not incurred in or aggravated by the Veteran's service, and may not be presumed to have been incurred in service, including from herbicide exposure in Vietnam. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002 and Supp. 2011); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA has a duty to notify and a duty to assist claimants in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.326(a) (2012). Proper notice must inform the claimant of any information and evidence not of record that is necessary to substantiate the claim. The claimant should be informed as to what portion of the information and evidence VA will seek to provide, and what portion of such the claimant is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Notice should be sent prior to the initial rating decision or, if sent after the rating decision, before a readjudication of the appeal. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006), The notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA may proceed with adjudication of a claim if errors in the timing or content of the notice are not prejudicial to the claimant or are cured by subsequent readjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Sanders v. Nicholson, 487 F.3d 892 (Fed. Cir. 2007). VA provided the Veteran with complying notice in March 2004 pre-adjudication letters. The March 2004 letters informed the Veteran to let VA know of any evidence he thought would support his claim of entitlement to service connection for diabetes mellitus and that it was his responsibility to make sure that VA received all requested records not in the possession of a Federal entity, and told him where to send evidence. The notice requirements apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO informed the Veteran of those elements in a March 2006 letter. The Board finds that VA satisfied its duty to notify. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2012). Neither the Veteran nor his representative has alleged prejudice with respect to notice. Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008). VA also fulfilled its duty to assist the Veteran by obtaining all relevant evidence in support of his claim of entitlement to service connection for diabetes mellitus, and therefore appellate review may proceed without prejudice. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012); Bernard v. Brown, 4 Vet. App. 384 (1993). The RO obtained his service medical and personnel records and VA treatment records, to include reports uploaded to the Veteran's Virtual VA electronic records system, and identified private treatment records. Also of record are copies of excerpts from monthly historical summaries of United States Naval Forces in Vietnam from May to August 1970. In addition, in a September 2010 response to VA's request for records, the Social Security Administration (SSA) reported that they were not able to locate any medical records of the Veteran, and that any further efforts would be futile. In response to the Board's September 2011 remand directives, the Joint Services Records and Research Center (JSRRC) submitted a report that specifically indicated that deck logs for the USS Advance did not show that it had entered any river or waterway in the Republic of Vietnam during operations. The Veteran's representative has argued that JSRRC's report is insufficient because only a summary of the USS Advance deck logs was provided, as opposed to the actual deck logs, as requested by the RO. Although the RO requested the actual deck logs from the JSRRC, the Board did not make such a request in its September 2011 remand directives. The Board finds no reason to question the validity or completeness of the JSRRC's review of the USS Advance deck logs during the period which the Veteran served. Thus, the Board finds that the RO substantially complied with its September 2011 remand directives regarding verification of the USS Advance areas of operation. Dyment v. West, 13 Vet. App. 141 (1999). In addition, the Board finds that a VA compensation examination is not needed to determine whether the Veteran's diabetes mellitus is related to his service. McClendon v. Nicholson, 20 Vet. App. 79 (2006); Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). Although a current diagnosis of diabetes mellitus is established, a nexus opinion is not necessary, because it has not been established that the Veteran was exposed to herbicides in service in Vietnam and the evidence does not indicate any other manner in which the diabetes mellitus may be related to the Veteran's service. The outcome of this appeal essentially turns on determining whether or not the Veteran had service in Vietnam or was otherwise exposed to herbicides during service. However, there is no objective indication of any confirmed service in the Republic of Vietnam, or that the USS Advance operated on the inland water in Vietnam during the Vietnam Era that might allow the Board to presume herbicide exposure. Therefore, a medical opinion to address the presumption of service connection is not necessary. Had exposure to herbicides been established, then an examination would not be necessary as a presumption of service connection exists for Veteran's exposed to herbicides during service. As for the possibility of direct-service-incurrence, there is no competent and credible indication that his diabetes mellitus is directly attributable to the Veteran's period of active service. There is no competent evidence of in-service incurrence of diabetes mellitus in his service treatment records. The Veteran does not contend that the onset occurred in service or within a year of service discharge. He does not allege that his diabetes mellitus is related to service other than by his alleged exposure to herbicide agents. The Board is not obligated to request an opinion when there is no suggestion of a relevant disease or injury in service that could be associated with the currently claimed disability. Charles v. Principi, 16 Vet. App. 370 (2002). Consequently, there is no reasonable possibility of substantiating the claim for service connection for diabetes mellitus, to include as due to herbicide exposure on a direct or presumptive basis by obtaining a medical opinion. Therefore, a VA medical opinion is not warranted. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the diabetes mellitus issue has been met. 38 C.F.R. § 3.159(c)(4) (2012). The Board concludes that all the available records and medical evidence has been obtained in order to make an adequate determination as to the claim for service connection for diabetes mellitus. Therefore, no further notice or assistance is required to fulfill VA's duty to assist in the development of this claim. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 18 (2002). The Board finds that VA has complied with the duty to assist requirements. 38 U.S.C.A. § 5103A (West 2002). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995). Inservice incurrence and a nexus to service may be established by showing continuity of symptomatology. Continuity of symptomatology may be shown by demonstrating (1) that a condition was noted during service or any applicable presumption period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Whether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a), such as diabetes mellitus. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). If there is at least an approximate balance of positive and negative evidence regarding any issue material to the claim, reasonable doubt shall be resolved in favor of the claimant in resolving each such issue. 38 U.S.C.A. § 5107 (West 2002); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); 38 C.F.R. §§ 3.102 (2012). However, if the Board determines that the preponderance of the evidence is against the claim, the claim must be denied. Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Certain diseases associated with exposure to herbicide agents may be presumed to have been incurred in service even if there is no evidence of the disease in service, provided the requirements of 38 C.F.R. § 3.307(a)(6) are met. 38 C.F.R. § 3.309(e) (2012). A Veteran who, during active service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. The last date on which a Veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. The term herbicide agent means a chemical in an herbicide, including Agent Orange, used in support of the United States and allied military operations in the Republic of Vietnam during the Vietnam era. 38C.F.R. § 3.307(a) (2012). If a Veteran was exposed to an herbicide agent during active service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: Chloracne or other acneform disease consistent with chloracne; Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes); Hodgkin's disease; chronic lymphocytic leukemia; B cell leukemia, Parkinson's disease, multiple myeloma; non-Hodgkin's lymphoma; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx or trachea); soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma); and ischemic heart disease, (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina). 38 C.F.R. § 3.309(e) (2012). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the Veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii) (2012). VA limits the presumption of exposure to Veterans who served on the ground or on the inland waterways of Vietnam and excludes Veterans who served aboard ships operating on Vietnam's offshore waters. Service in the Republic of Vietnam includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii) (2012). Service on a deep-water naval vessel off the shores of Vietnam without proof of actual duty or visitation in the Republic of Vietnam is not considered service in the Republic of Vietnam during the Vietnam era beginning on February 28, 1961, and ending on May 7, 1975. 38 U.S.C.A. § 101(29)(A) (West 2002); VAOPGCPREC 27-97 (1997), 62 Fed. Reg. 63604 (1997). VA has reiterated its position that service in deep-water naval vessels offshore of Vietnam, as opposed to service aboard vessels in inland waterways of Vietnam is not included as service in the Republic of Vietnam for purposes of presumptive service connection for Agent Orange diseases. 66 Fed. Reg. 23166 (May 8, 2001). In addition, several VA materials have restated the position. The VA Adjudication Procedure Manual, M21-1MR, contains a note that service aboard a ship that anchored in an open deep-water harbor, such as Da Nang, Vung Tau, or Cam Rahn Bay, along the RVN coast does not constitute inland waterway service or qualify as docking and is not sufficient to establish presumptive exposure to herbicides. Evidence of shore docking is required in order to concede the possibility that the Veteran's service involved duty or visitation in the RVN. M21-MR, IV.ii.1.H.28.h. A February 2009 VA Compensation & Pension Service Bulletin indicates that if development shows evidence that a Veteran served aboard a ship that docked on the shores of Vietnam and places the Veteran aboard the ship at that time, and the Veteran provides a statement that he went ashore, that will be sufficient evidence to establish a presumption of herbicide exposure. The bulletin clarifies that the evidence must indicate that the ship actually docked on shore, and that service aboard a ship anchored in an open deep-water harbor such as Da Nang is not the same as docking to the shore. Evidence of shore docking is required. In January 2010, VA released a Compensation and Pension bulletin indicating that a number of offshore naval vessels conducted operations on the inland rivers and delta areas of Vietnam. The Bulletin stated that if a Veteran was on board one of the specifically named vessels that engaged in inland waterway service, during a specific time period, then the Veteran may be presumed to have been exposed to herbicides. The USS Advance is not one of the ships listed in the January 2010 Bulletin as having operated on the inland waters. Also, a September 9, 2010, Training Letter refers to a longer list of identified vessels potentially exposed to herbicides, particularly: (1) individual vessels, and types of vessels, that operated primarily or exclusively on the inland waterways, and (2) individual vessels that temporarily operated on inland waterways or docked, with dates. The list was updated November 8, 2012. However, that list did not include the USS Advance as having operated on the inland waterways of Vietnam. For purposes of applying the presumption of exposure to herbicides under 38 C.F.R. § 3.307(a)(6)(iii), the serviceman must have actually been present at some point on the landmass or the inland waters of Vietnam during the Vietnam conflict. Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008). Where the evidence does not warrant presumptive service connection, an appellant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Veteran seeks service connection for diabetes mellitus, type 2. He maintains that his currently diagnosed diabetes mellitus, type 2, is the result of having been exposed to herbicides while serving aboard the USS Advance (MSO 510), during Operation Market Time, an operation to patrol along the coasts, rivers, and harbors of the Republic of Vietnam (RVN). In March and April 2004, he maintained that he did not disembark onto the landmass of the RVN. The Board finds that the preponderance of the evidence of record does not show that it is at least as likely as not that the Veteran's diabetes mellitus, type 2, was manifested to a compensable degree within a year of service discharge, is etiologically related to his military service, to include exposure to herbicides, or that the Veteran served in the RVN during the Vietnam era. Therefore, his claim must be denied. The Board initially finds that diabetes mellitus is a listed disease under § 3.309(e). The Veteran was initially diagnosed with diabetes mellitus, type 2, in February 2004 as shown in a statement prepared by L.L.F., A.R.N.P., dated in March 2004showing treatment of diabetes, type 2 with medication and diet. The Veteran does not allege, and his service records do not show, that diabetes mellitus manifested during active service. His May 1969 enlistment examination and November 1970 separation examination reports were unremarkable for any clinical findings or any diagnosis of diabetes mellitus. There is also no indication of in-service incurrence, since the service treatment records show no objective complaints, treatments, or diagnoses of any diabetes mellitus during active duty. The Veteran was initially diagnosed with diabetes mellitus in 2004, over three decades after service discharge in 1970. Without there being any indication that diabetes mellitus was initially manifested to a compensable level within one year following service discharge in November 1970, presumptive service connection for chronic diseases, under 38 C.F.R. § 3.309(a), is not warranted. 38 U.S.C.A. § 1101, 1112, 1113 (West 2002); 38 C.F.R. § 3.307, 3.309 (2012). The Veteran has also made no allegation of continuity of diabetes mellitus symptomatology since active service. The Veteran instead contends that his diabetes mellitus, type 2, was the result of exposure to herbicides while conducting mine sweeping operations off the coast of the RVN during Operation Market Time while serving aboard USS Advance (MSO-510) from 1969 to 1970. He has been consistent in that argument. However, the Board finds that the evidence of record is against a finding that the Veteran was exposed to herbicide agents during service. The record does not show that the Veteran had any confirmed service in the Republic of Vietnam during the Vietnam War, to include service in the inland waterways of Vietnam. The Veteran's service separation form shows that he served aboard the USS Advance (MSO-510) and that he had 11 months and 22 days of foreign or sea service. He was awarded the Vietnam Service Medal and National Defense Service Medal. However, those awards do not established that the Veteran served in the Republic of Vietnam. The Veteran's service personnel records show that he served aboard the USS Advance when it was in the Vietnam Theater of Operations from May 15, 1970, to June 18, 1970, and from July 13, 1970, to August 5, 1970. Thus, the Veteran's claim hinges on whether the he had any inland waters service while serving aboard the USS Advance (MSO-510) during service. The Board finds that the preponderance of the competent evidence of record is against a finding that the Veteran served in the Republic of Vietnam during the Vietnam era. USS Advance is not listed as a Navy vessel that operated on the inland waterways of Vietnam. Pursuant to the Board's September 2011 remand directives, in a September 2011 response, JSRRC concluded that the USS Advance command history revealed that it had conducted mine sweeping operations along the coast of Vietnam for two extended periods during the summer of 1970. The ship was noted to have earned five battle stars during the Vietnam Conflict. JSRRC indicated that a review of the USS Advance deck logs for the periods from May 15 to June 18, 1970 and July 13, to August 5, 1970, obtained from the National Archives and Records Administration (NARA), showed that it had conducted Market Time Patrols during those time periods. The deck logs further documented that in May and July 1970, and on August 4, 1970, the USS Advance anchored in Vung Tau Harbor and Conson Bay, RVN. JSRRC specifically indicated that deck logs did not document that the USS Advance had traveled inland waterways in the RVN. JSRRC reported that several servicemen had departed the USS Advance on June 5, 1970, on a coastal patrol boat. The Veteran was not listed as one of those individuals. In essence, JSRRC's search of the USS Advance deck logs for the May 15 to June 18, 1970 and July 13, to August 5, 1970, provided no conclusive proof of in-country service in the Republic of Vietnam, such as the vessel having docked to the shore. Therefore, because the evidence does not show that the Veteran served in the Republic of Vietnam, to include the inland waters, the criteria for presumptive service connection on the basis of herbicide exposure have not been satisfied. In conclusion, after careful review of the medical and lay evidence of record and the pertinent law and regulations, the Board finds that there is no competent evidence that the Veteran was exposed to herbicides during his service. The presumption of service connection therefore does not attach. The evidence does not show, that diabetes mellitus manifested during service or within one year following discharge from service. Moreover, there is no competent evidence linking diabetes mellitus to service and no competent evidence establishing that the Veteran was actually exposed to herbicides during his service or that the USS Advance (MSO-510) had inland waters service while in the Vietnam Theater of Operations from May 15, 1970, to June 18, 1970, and from July 13, 1970, to August 5, 1970. Thus, although the Veteran believes that the USS Advance operated on inland waterways while he was stationed aboard that ship, the objective evidence of record does not support that contention. His assertion of exposure is outweighed by the objective evidence of record, which does not establish such exposure. The Veteran has denied going ashore in Vietnam. Finally, the Board notes that although the Veteran believes that his diabetes mellitus is due to service, generally etiology of dysfunctions and disorders is a medical determination. Lay persons are competent to provide opinions on some medical issues. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, as to the issue as to whether the Veteran's diabetes mellitus is related to service, that is a question that falls outside the realm of common knowledge of a lay person. A lay person is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions. The Veteran, as a lay person without the appropriate medical training and expertise, is not competent to make such a medical determination, especially in light of the fact that the evidence fails to demonstrate the onset of his diabetes in, or within one year of, service. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board concludes that the preponderance of the evidence is against the claim for service connection for diabetes mellitus, to include as due to herbicide exposure. Therefore is no reasonable doubt to be resolved. Therefore, the appeal is denied. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for diabetes mellitus, to include as secondary to herbicide exposure, is denied. REMAND The Board finds that the claim for service connection for a cardiovascular disorder, to include as secondary to herbicide exposure, diabetes mellitus, and PTSD must be remanded for additional development. Specifically the remand is needed to comply with the Board's September 2011 remand directives. The claim was previously remanded by the Board in September 2011 for a VA examination to determine the etiological relationship, if any, between any currently diagnosed cardiovascular disorder and service-connected PTSD. The Board finds that the September 2011 remand orders have not been satisfied. Dyment v. West, 13 Vet. App. 141 (1999); Stegall v. West, 11 Vet. App. 268 (1998). In its September 2011 remand, the Board noted that in support of his claim for service connection for coronary artery disease, the Veteran had submitted a December 2005 statement, authored by L.F., N.P. In that statement, L.F., N.P. opined that the Veteran had coronary artery disease that "I think [in part] stems from his (PTSD)." In view of this statement, the Board directed that the RO schedule the Veteran for a VA examination to determine whether the Veteran's coronary artery disease was related to his service-connected PTSD. VA examined the Veteran in October 2011. A review of the examination report shows that the VA examiner did not provide an opinion as to the etiological relationship between the Veteran's diagnosed coronary artery disease and the service-connected PTSD. Thus, the requests of the Board in the September 2011 remand were not adequately completed. A remand of this claim is necessary to ensure compliance with the prior Board remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination with a medical doctor to determine the nature, extent and etiology of any cardiovascular disorder noted on examination. The examiner must review the claims file and must note that review in the report. Upon a review of the record and examination of the Veteran, the examiner must opine whether it is at least as likely than not (50 percent probability or greater) that any currently diagnosed cardiovascular disorder is etiologically due to, or has been aggravated by service-connected PTSD. Aggravated means a permanent worsening of the underlying condition beyond the natural progress of the disorder, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. 2. Then readjudicate the claim. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the claim to the Board. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs