Citation Nr: 1316047 Decision Date: 05/15/13 Archive Date: 05/29/13 DOCKET NO. 10-19 980 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for hypertension, to include as due to in-service appendicitis and peritonitis. 2. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for a stomach disorder (gastrointestinal disorder), to include as due to in-service appendicitis and peritonitis. 3. Entitlement to service connection for a lung disorder. 4. Entitlement to service connection for coronary artery disease, to include as due to hypertension, to include as due to in-service appendicitis and peritonitis. 5. Entitlement to service connection for a psychiatric disorder, to include vascular dementia, to include as due to coronary artery disease and hypertension. 6. Entitlement to service connection for a lumbar spine disorder, to include as due to surgery for coronary artery disease. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. H. Stubbs, Counsel INTRODUCTION The Veteran served on active duty from January 1951 to October 1955 and from January 1956 to January 1960. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. In March 1996, the RO found that new and material evidence had not been submitted to reopen a claim of entitlement to service connection for hypertension. In April 1996, the Veteran filed a notice of disagreement with this decision, and in June 1996 he indicated he wished to appeal the issue to the Board of Veterans Appeals. The Statement of the Case was provided in July 1996, and so unfortunately his June 1996 statement requesting to appeal the decision was untimely. See 38 C.F.R. § 20.302(b). In January 1998, the RO denied the Veteran's claim to reopen claims of entitlement to service connection for hypertension and an ulcer. The Veteran filed a timely notice of disagreement and was provided with a Statement of the Case in March 1999. The Veteran did not file a substantive appeal of the January 1998 decision. This appeal was previously before the Board in June 2012. The Board addressed the new and material evidence claims on appeal on a direct basis in error. A review of the claims file reveals that the Veteran has been previously denied entitlement to service connection for hypertension and for a gastrointestinal disorder ("stomach problems"). The RO, in the August 2009 rating decision on appeal, additionally addressed the claims as service connection claims, and thus the Board presumes the RO found evidence that new and material evidence had been submitted, but determined the evidence was insufficient to grant entitlement to service connection. Despite the determination reached by the RO, the Board must make its own finding regarding new and material evidence in order to establish its jurisdiction to review the merits of a previously denied claim. See Barnett v. Brown, 83 F. 3d 1380 (Fed. Cir. 1996). The issue of entitlement to service connection for dermatitis was before the Board in June 2012, and was remanded for additional development. In a January 2013 rating decision, entitlement to service connection for dermatitis was granted. As this is a full grant of the benefit on appeal, the issue is no longer before the Board. Additionally, in June 2012, the Board remanded the issues on appeal so that the Veteran could receive corrective notice, treatment records could be requested, and the Veteran could be scheduled for VA examinations. The case has been returned to the Board for further appellate consideration. 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: hypertension, a gastrointestinal disorder, coronary artery disease, a psychiatric disorder, and a lumbar spine disorder are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Entitlement to service connection for hypertension was initially denied in a January 1970 rating decision. In January 1998, an additional rating decision found that new and material evidence had not been submitted to reopen a claim of entitlement to hypertension. After the Veteran filed a notice of disagreement, the RO again denied reopening the claim in a March 1999 statement of the case. 2. The evidence received since the March 1999 decision includes evidence that is neither cumulative nor redundant, relates to an unestablished fact necessary to substantiate the claim for service connection for hypertension and raises a reasonable possibility of substantiating the claim. 3. Entitlement to service connection for a gastrointestinal disorder, claimed as "stomach problems," was initially denied in a January 1970 rating decision. Subsequently, in a January 1998 rating decision the RO found that new and material evidence had not been submitted to reopen a claim of entitlement to duodenal ulcer disease. After the Veteran filed a notice of disagreement, the RO again denied reopening the claim in a March 1999 statement of the case. 4. The evidence received since the March 1999 decision includes evidence that is neither cumulative nor redundant, relates to an unestablished fact necessary to substantiate the claim for service connection for a gastrointestinal disorder and raises a reasonable possibility of substantiating the claim. 5. The Veteran does not suffer from a chronic lung disorder. CONCLUSIONS OF LAW 1. The March 1999 decision which found that new and material evidence had not been submitted sufficient to reopen a claim of entitlement to service connection for hypertension is final. 38 U.S.C.A. § 7105 (West 2002 & Supp. 2012). 2. New and material evidence has been received to reopen the claim of entitlement to service connection for hypertension. 38 C.F.R. § 3.156 (2012). 3. The March 1999 decision which found that new and material evidence had not been submitted sufficient to reopen a claim of entitlement to service connection for a gastrointestinal disorder is final. 38 U.S.C.A. § 7105. 4. New and material evidence has been received to reopen the claim of entitlement to service connection for a gastrointestinal disorder. 38 C.F.R. § 3.156. 5. The criteria for establishing entitlement to service connection for a chronic lung disorder have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Board has thoroughly reviewed all the evidence in the appellant's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). 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; 38 C.F.R. §§ 3.102 , 3.156(a), 3.159, 3.326(a). 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); 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 should provide in accordance with 38 C.F.R. § 3.159(b)(1). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006). Regarding the issue of entitlement to service connection for a chronic lung disorder, the Board finds that the Agency of Original Jurisdiction (AOJ) has substantially satisfied the duties to notify and assist, as required by the VCAA. The Veteran was provided with a letter fulfilling VCAA notice requirements in April 2009. The letter additionally provided notice regarding how disability ratings and effective dates are assigned in accordance with Dingess. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Additionally, VA treatment records are contained in the claims file and in Virtual VA, and the Veteran has been afforded an adequate VA examination. The Veteran indicated he applied for Social Security Administration (SSA) disability compensation. An attempt to obtain SSA records was returned as unavailable, and noted the records associated with the Veteran's claim had been destroyed. Regarding the new and material evidence claims on appeal, the Veteran was not provided with notice which explained the definition of new and material evidence and of the bases for his prior denials. See Kent v. Nicholson, 20 Vet. App. 1 (2006). However, to the extent that there may be any deficiency of notice or assistance, there is no prejudice to the appellant proceeding with these new and material evidence issues given the favorable nature of the Board's decision with regard to reopening the claims. New and Material Evidence A decision of the RO becomes final and is not subject to revision on the same factual basis unless a notice of disagreement is filed within one year of the notice of the decision. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 20.302, 20.1103. If a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C.A. § 5108 (West 2002); see Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). VA must review all the evidence submitted since the last final rating decision in order to determine whether the claim may be reopened. See Hickson v. West, 12 Vet. App. 247, 251 (1999). New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). Furthermore, the Court of Appeals for the Federal Circuit has indicated that evidence may be considered new and material if it contributes "to a more complete picture of the circumstances surrounding the origin of a veteran's injury or disability, even where it will not eventually convince the Board to alter its ratings decision." Hodge v. West, 115 F.3d 1356, 1363 (Fed. Cir. 1998). For purposes of determining whether new and material evidence has been received to reopen a finally adjudicated claim, the recently submitted evidence will be presumed credible. See Kutscherousky v. West, 12 Vet. App. 369, 371 (1999) (per curium) (holding that the "presumption of credibility" doctrine continues to be precedent). In January 1970, the Veteran's claim for service connection for a gastrointestinal disorder, claimed as "stomach problems," was denied because his service treatment records did not show cholelithias or a duodenal ulcer. Subsequently, the Veteran filed a claim to reopen a claim of entitlement to service connection for a duodenal ulcer. His claim was denied in a January 1998 rating decision. Although the Veteran filed a notice of disagreement with this decision, he did not substantively appeal the decision subsequent to receiving a statement of the case in March 1999. The Veteran did not appeal this decision and it became final. The evidence of record at the time of the March 1999 decision included service treatment records, a September 1969 VA treatment record, a June 1969 VA examination, and additional VA treatment records supplied by the Veteran. The September 1969 treatment record indicated the Veteran had gallbladder stones on x-ray, and an intolerance to fatty meals with gastric burning sensations and flatulence. The diagnosis of a duodenal ulcer was excluded. The June 1969 VA examiner diagnosed duodenal ulcer. Evidence that has been added to the claims file since the March 1999 decision include VA treatment records diagnosing GERD and a hiatal hernia. Additionally, in April 2013, the Veteran's representative provided an internet article which indicates that pylephlebitis may result in venous collaterals in the hepatoduodenal. In January 1970, the Veteran's claim for service connection for hypertension was denied because his hypertension was noted to have been diagnosed in 1963. He was noted to have essential hypertension during the June1969 VA examination. The September 1969 treatment record indicated his hypertension began in 1960, according to the history provided by the Veteran. Subsequently, the Veteran filed a claim to reopen a claim of entitlement to service connection for hypertension. His claim was denied in a January 1998 rating decision. Although the Veteran file d a notice of disagreement with this decision, he did not substantively appeal the decision subsequent to receiving a statement of the case in March 1999. The Veteran did not appeal this decision and it became final. The evidence of record at the time of the March 1999 statement of the case included the Veteran's service treatment records, the September 1969 VA examination, a July 1978 VA examination, and some VA treatment records. Evidence that has been added to the claims file since the July 1996 rating decision includes the article on pylephlebitis provided in April 2013. The article notes that a complication of pylephlebitis is portal hypertension. The additional evidence is "new" in that it was not previously before agency decision makers at the time of the January 1970 and July 1996 decision, and is not cumulative or duplicative of evidence previously considered. As the evidence submitted is presumed credible for the purposes of reopening a claim, the Veteran's statements, the article on pylephlebitis, and the additional diagnoses are "material" evidence of a current disability and continuity of symptomatology. This evidence alone or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Consequently, the new evidence raises a reasonable possibility of substantiating the Veteran's claims of entitlement to service connection for hypertension and a gastrointestinal disorder. Under these circumstances, the criteria to reopen the claims of entitlement to service connection for hypertension and a gastrointestinal disorder are met. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. Service connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). In order to prevail on the issue of service connection there must be: (1) medical evidence of a current disability; (2) medical evidence, or in certain circumstances, lay evidence of in- service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Pond v. West, 12 Vet App. 341, 346 (1999). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993); see also Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). Service treatment records do not contain any complaints of, treatment for, or diagnosis of a respiratory disorder. An October 1954 treatment record noted the Veteran was treated for the common cold. On his October 1955 separation evaluation he was noted to have a normal evaluation of the lungs and chest. Although he did not report a history of whooping cough during his January 1956 enlistment evaluation or during his prior enlistment from 1951 to 1955, the Veteran indicated he had whooping cough in his childhood on his January 1960 separation evaluation. He denied complications as a result of his childhood whooping cough. Evaluations of his lungs and chest were normal. A January 1959 chest x-ray revealed clear lung fields. During a June 1969 VA examination, the Veteran's lung fields were clear. He was not diagnosed with a respiratory disorder. His lungs were noted to be "essentially clear to all" during a December 1978 VA examination and he was not diagnosed with a respiratory disorder. In August 1995, the Veteran underwent cardiac surgery. An x-ray prior to surgery revealed well-expanded and grossly clear lung fields. Subsequent to the surgery, a September 1995 x-ray revealed status post sternotomy due to coronary bypass surgery, with the possibility of a pleural reaction in the left lung. Ten days later, an x-ray revealed findings compatible with pleural thickening, which was noted as "post-surgical changes." In October 1996, the Veteran was noted to have a small calcified granuloma of the outer 3rd of the left upper lobe by x-ray. There was no evidence of acute pleuropulmonary infiltrates. In April 1997, the Veteran was afforded a VA general medical examination. His lungs were clear to auscultation and percussion and he was not diagnosed with a respiratory disorder. The Veteran filed a claim for entitlement to service connection for a "lungs condition" in February 2009. He indicated that his condition was "incurred coincidental to my military service." A June 2009 x-ray noted the Veteran had bronchiectatic changes in the right lung apex, however, he was not diagnosed with a lung disorder. A March 2011 chest x-ray noted the Veteran had a stable sternotomy with postoperative changes below the left diaphragm. The lungs had a stable hypoventilatory change with improving right lung aeration. In December 2011, the Veteran complained of a nonproductive cough being one day prior, and a fever from the night before. The diagnostic impression was "allergic rhinitis, upper respiratory infection, bronchitis," and he was started on antibiotics. Less than a week later he was assessed with "resolving" acute bronchitis, and he was noted to not need a respiratory inhaler. In November 2012, the Veteran was afforded a fee basis VA respiratory conditions evaluation. The examiner noted that the Veteran has been diagnosed with a common cold in 1954 and with acute bronchitis in 2011. The examiner noted that the Veteran was not diagnosed with any other respiratory disorders according to the medical records in the claims file and in electronic medical records. The Veteran denied a history of asthma, chronic bronchitis, emphysema or other pulmonary conditions during the evaluation. He denied shortness of breath, chronic cough, excessive sputum or other pulmonary symptoms. The examiner noted that pulmonary function tests were not administered during the evaluation because the Veteran's conditions (common cold, and bronchitis) had resolved. The examiner found that there was no evidence of a current respiratory condition or lung disorder. Here, the Veteran has claimed that he has a lung condition as a result of his military service. However, during his 2012 VA evaluation, the Veteran denied shortness of breath, chronic cough, excessive sputum and other pulmonary symptoms. He also stated he had not been diagnosed with any pulmonary conditions other than the common cold and acute bronchitis. Thus, while a lay person is competent to provide statements regarding any symptoms he may experience, here, the Veteran has denied respiratory symptoms. Treatment records from the 1960s and 1970s did not include treatment for any lung or respiratory disorders. Treatment records show that both the Veteran's cold and bronchitis resolved without sequelea. The 2012 evaluator found that the Veteran did not suffer from a current respiratory or lung disorder. Additional VA treatment records indicate that the Veteran had moderate dyspnea is associated with his coronary artery disease. As noted above, in the absence of proof of a current lung or respiratory disorder, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer, 3 Vet. App. at 225. In the absence of any competent evidence of a lung disorder, the Board must conclude the Veteran does not currently suffer from such a disability, and the Board must deny the Veteran's claim. See Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). Without a diagnosed chronic lung disorder service connection for such disorder cannot be granted. Thus, the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim of service connection a chronic lung disorder must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). ORDER New and material evidence having been received; the claim of entitlement to service connection for hypertension is reopened. New and material evidence having been received; the claim of entitlement to service connection for a gastrointestinal disorder is reopened. Entitlement to service connection for a lung disorder is denied. REMAND Unfortunately, a remand is required in regards to the Veteran's claim. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. Such development would ensure that his due process rights, including those associated with 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326, are met. The Veteran suffered from acute appendicitis with perforation during service, and underwent an appendectomy. He then developed pylephlebitis and infection of the wound site. Additionally, the Veteran was treated for mumps in service. The Veteran initially filed a claim of entitlement to service connection for hypertension in April 1969. Treatment records, rating decisions and VA examination reports from 1969 variously note that the Veteran's hypertension began in 1960, 1963, and 1966. The earliest medical documentation of hypertension is from 1969. During his separation from service in January 1960, the Veteran's blood pressure was 108/82. The Veteran contends that he is entitled to service connection for hypertension because (1) his hypertension began during service, or (2) his hypertension began as a result of the residuals of his appendicitis, peritonitis and pylephlebitis. The Veteran contends that he is entitled to service connection for gastrointestinal disorders due to the residuals of his appendicitis, peritonitis and pylephlebitis. A September 1976 treatment record indicated the Veteran had severe residuals of surgery for peritonitis, probably due to intestinal adhesions. Regarding the Veteran's contentions that his hypertension and gastrointestinal disorders are due to or a result of the residuals of his appendicitis, his representative has provided an article on pylephlebitis. The article indicates that complications of pylephlebitis include portal hypertension and venous collaterals in the hepatoduodenal ligament. Additionally, the Veteran argues that as a result of his hypertension he developed coronary artery disease/heart disease. Subsequent to surgery for coronary artery disease, the Veteran suffered a cerebrovascular accident which he argues caused his vascular dementia. In simpler terms, the Veteran argues that his residuals of appendicitis caused him to develop hypertension, which caused him to develop heart disease, which lead to a cerebrovascular accident which caused vascular dementia. The Veteran has also stated that his back pain began, and has continued since, his coronary artery surgery. The Veteran has been afforded VA examinations in 2009 and 2012 to address his claim, however, the rationales do not provide the necessary information for the Board to make a decision and are thus inadequate. As noted in the prior July 2012 Board remand, "none of the examiners provided comments as to whether the appellant's peritonitis may have caused or resulted in the development of gastroesophageal reflux disease or if the appendicitis and peritonitis may have encouraged the developed of a psychiatric disorder from which he now suffers. Moreover, none of the examiners provided any type of comments concerning the appellant's statements concerning the chronicity of the symptoms he claimed had existed since leaving service." The Board is obligated by law to ensure that the RO complies with its directives, as well as those of the United States Court of Veterans Appeals (Court). The Court has stated that compliance by the Board or the RO is neither optional nor discretionary. Where the remand orders of the Board or the Court are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). The 2012 evaluator noted that the Veteran's vascular dementia was caused by cerebrovascular accidents and that his vascular dementia has "no relationship with his appendectomy with peritonitis (neither secondary to it nor aggravated by it)." The examinations contain both "there is no evidence of a stomach disorder" and an opinion regarding gastroesophageal reflux disorder. While she addressed his in-service episode of gastroenteritis, she repeated the 2009 examiner's statement that "[GERD, coronary artery disease, and hypertension] are different medical entities with different pathophysicolgoical mechanisms, not etiologically related to an appendectomy scar." Regarding his heart disease, the evaluator noted "medical literature does not support an etiologic link between coronary artery disease...and an appendectomy scar." Similarly, she stated "medical literature does not support an etiologic link between hypertension and an appendectomy scar." The Veteran is currently service connected for his appendectomy scar, but he can be service connected for any residual of his in-service appendicitis and subsequent infection and pylephlebitis. The 2009 and 2012 opinions and rationales do not address direct service connection. The evaluator also misunderstood the Veteran's contentions, as he argued his hypertension and GERD are due to his appendicitis and pylephlebitis, but that his heart disease is due to his hypertension. The mental health evaluation addressed vascular dementia, but did not address the Veteran's diagnosis of depression, to include if he currently suffers from depression. Lastly, the Veteran's lumbar evaluation notes "the claims file does not show evidence of any lumbar conditions. Actual discogenic disease is most likely related to aging." The claims file and Virtual VA include diagnoses of multilevel degenerative changes. The Veteran has stated that his back pain began following his heart surgery and continued since. As a decision has not been made regarding the Veteran's claim for hypertension and heart disease, a decision cannot be made regarding his lumbar spine claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). As the claims are being remanded, the evaluator should address whether the Veteran's heart surgery caused his low back disability. Accordingly, the case is REMANDED for the following action: (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. If possible, the claims file should be returned to the November 2012 evaluator for an addendum opinion. The claims folder, Virtual VA and a copy of this remand are to be made available to the examiner to review prior to the review. All necessary tests should be conducted and the examiner should review the results of any testing prior to completion of the report. The examiner should express an opinion regarding the following: a) Is it at least as likely as not (a probability of 50 percent or greater) that the Veteran's hypertension is due to his military service? Please address the hypertension onset dates provided in June and September 1969 records. b) Is it at least as likely as not that the Veteran's hypertension developed as a result of his in-service appendicitis and its complications (infection/peritonitis/pylephlebitis)? Please address the pylephlebitis article in your response. c) Is it as least as likely as not that the Veteran developed a gastrointestinal disorder as a result of his military service? Please address all diagnosed gastrointestinal disorders. d) Is it at least as likely as not that the Veteran developed a gastrointestinal disorder as a result of his in-service appendicitis and its complications (infection/peritonitis/pylephlebitis)? Please address the September 1976 record addressing intestinal adhesions and the article on pylephlebitis. e) If you determine that the Veteran's hypertension is related to his service or his in-service appendicitis and its complications, then is it at least as likely as not the Veteran's hypertension caused or aggravated the Veteran's coronary artery disease? f) If you determine the Veteran's hypertension caused or aggravated his coronary artery disease, then is it at least as likely as not the Veteran's coronary artery disease caused his vascular dementia? g) If you determine the Veteran's hypertension caused or aggravated his coronary artery disease, then is it at least as likely as not the Veteran's 1995 coronary surgery caused or aggravated his lumbar spine degenerative changes? The examiner must provide complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the provided conclusions. If further testing or examination by other specialists is determined to be warranted in order to evaluate the conditions at issue, such testing or examination is to be accomplished prior to completion of the examination reports. The examiner should not invoke the phrase "without resort to mere speculation" without first explaining the basis for such an opinion. That is, if the examiner is unable to provide the requested opinion without resorting to speculation, the examiner must provide an explanation for the basis of that determination, for example, does the examiner lack the expertise to render such an opinion, or is some additional testing or information needed, and possibly available, which would permit an opinion. If so, a qualified examiner should provide an opinion and/or the additional testing should be accomplished. If the examiner cannot provide an opinion because it cannot be determined from current medical knowledge whether a specific in-service injury or disease can possibly cause the claimed condition, or the actual cause cannot be selected from multiple potential causes, this should be fully explained. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). 2. The RO/AMC should review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. Specific attention is directed to the reports of examination. If the requested reports do not include fully detailed descriptions of pathology and all test reports, special studies or adequate responses to the specific opinions requested, the reports must be returned for corrective action. 38 C.F.R. § 4.2; see also Stegall v. West, 11 Vet. App. 268 (1998). 3. Thereafter, the RO/AMC should readjudicate the claims that are now on appeal after taking any other development action that is deemed warranted. If the benefits sought on appeal remain denied, the appellant and the appellant's representative should be provided a supplemental statement of the case (SSOC). The SSOC must contain notice of all relevant actions taken on the claim for benefits, to include a summary of the evidence and applicable law and regulations considered pertinent to the issues currently on appeal. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The purposes of this remand are to comply with due process of law and to further develop the appellant's claims. The appellant is advised that failure to cooperate by reporting for examinations may result in the denial of the claims. 38 C.F.R. § 3.655 and Connolly v. Derwinski, 1 Vet. App. 566, 569 (1991). The Board intimates no opinion, either legal or factual, as to the ultimate disposition warranted in this case, pending completion of the above. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). (CONTINUED ON NEXT PAGE) This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ C. TRUEBA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs