Citation Nr: 1319426 Decision Date: 06/14/13 Archive Date: 06/21/13 DOCKET NO. 08-25 517 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, the Republic of the Philippines THE ISSUES 1. Entitlement to service connection for coronary artery disease/hypertensive cardiovascular disease. 2. Entitlement to service connection for bilateral deep venous insufficiency. ATTORNEY FOR THE BOARD F. Yankey, Counsel INTRODUCTION The Veteran served on active duty from June 1962 to September 1982. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an October 2009 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). In October 2011, the Board remanded the case for further development by the originating agency. The case has been returned to the Board for further appellate action. The issue of entitlement to service connection for bilateral deep venous insufficiency is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran had active service on the waters offshore of Vietnam; he did not serve in or visit Vietnam, and was not otherwise exposed to Agent Orange. 2. Coronary artery disease/hypertensive cardiovascular disease was not present during active service or manifested to a degree of 10 percent within one year of the Veteran's discharge from service, nor is it etiologically related to active service. CONCLUSION OF LAW Coronary artery disease/hypertensive cardiovascular disease was not incurred or aggravated during active service and the incurrence or aggravation of coronary artery disease/hypertensive cardiovascular disease during active service may not be presumed. 38 U.S.C.A. §§ 1101, 1110, 1112, 1116 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012) defined VA's duty to assist a Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, 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. Pelegrini v. Principi (Pelegrini II), 18 Vet. App. 112, 120-21 (2004), see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In a November 2007 letter, issued prior to the initial adjudication of the claims, the RO notified the Veteran of the evidence needed to substantiate his claims for service connection. The letter satisfied the second and third elements of the duty to notify by informing the Veteran that VA would try to obtain medical records, employment records, or records held by other Federal agencies, but that he was nevertheless responsible for providing any necessary releases and enough information about the records to enable VA to request them from the person or agency that had them. The Veteran has substantiated his status as a Veteran. He was notified of all elements of the Dingess notice, including the disability-rating and effective-date elements of the claim in the November 2007 letter. VCAA notice should be provided to a claimant before the initial unfavorable decision on a claim, as was done here. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). The Duty to Assist The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). The VCAA also provides that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. VA has obtained service treatment records and assisted the Veteran in obtaining evidence. All known, identified, and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file, and the Veteran has not contended otherwise. VA requested information from the Veteran which might have been used to establish that he set foot on land in Vietnam during the Vietnam Era, but the Veteran did not provide sufficient specific information for a meaningful inquiry to be made to the service department regarding that likelihood. Additionally, the Veteran was provided a proper VA examination in September 2012 for his heart disability. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The appeal is thus ready to be considered on the merits. Legal Criteria Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (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. See Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). The theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As coronary artery disease is recognized as chronic under 38 C.F.R. § 3.309(a), the theory of continuity of symptomatology under 38 C.F.R. § 3.303(b) is for application. Id. In relevant part, 38 U.S.C.A. 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[l]ay 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); see also Buchanan v. Nicholson, 451 F.3d at 1337 ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). With chronic diseases shown as such in service, or within the presumptive period after service, so as to permit a finding of service connection, subsequent manifestation of the same chronic disease at any later date, however remote, are service-connected unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). § 3.303(b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests coronary artery disease to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. 38 U.S.C.A. § 1116(a) (West 2002) provides presumptive service connection on the basis of herbicide exposure for specified diseases manifested to a degree of 10 percent within a specified period in a Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. It also provides presumptive service connection on the basis of herbicide exposure for each additional disease that the Secretary determines in regulations prescribed under this section warrants a presumption of service-connection by reason of having a positive association with exposure to an herbicide agent, and that becomes manifest within the period (if any) prescribed in such regulations in a Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. Whenever the Secretary determines, on the basis of sound medical and scientific evidence, that a positive association exists between (A) the exposure of humans to an herbicide agent, and (B) the occurrence of a disease in humans, the Secretary shall prescribe regulations providing that a presumption of service connection is warranted for that disease for the purposes of this section. 38 U.S.C.A. § 1116(b)(1). In making determinations for the purpose of this subsection, the Secretary shall take into account (A) reports received by the Secretary from the National Academy of Sciences under section 3 of the Agent Orange Act of 1991 [note to this section], and (B) all other sound medical and scientific information and analyses available to the Secretary. In evaluating any study for the purpose of making such determinations, the Secretary shall take into consideration whether the results are statistically significant, are capable of replication, and withstand peer review. 38 U.S.C.A. § 1116(b)(2). The diseases presumed to be associated with herbicide exposure include: chloracne or other acneform diseases consistent with chloracne, type 2 diabetes (also known as type II diabetes or adult-onset diabetes), Hodgkin's disease, 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), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). An association between the occurrence of a disease in humans and exposure to an herbicide agent shall be considered to be positive for the purposes of this section if the credible evidence for the association is equal to or outweighs the credible evidence against the association. 38 U.S.C.A. § 1116(b)(3). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2010); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. At 54. Analysis Coronary artery disease/hypertensive cardiovascular disease was not diagnosed until many years after service and there is no medical opinion that purports to relate it to service. In fact, throughout the pendency of the appeal, the Veteran has reported that the disorder developed secondary to his diabetes mellitus, which he claims developed as a result of exposure to Agent Orange during active duty in Vietnam. As discussed further below, the Veteran was not diagnosed with diabetes until 2004, and was not diagnosed with coronary artery disease and hypertensive heart disease until 2005, more than 20 years after his discharge from service. Service treatment records show that blood pressure readings in 1968, 1978, 1979, and on discharge examination in 1982 were normal. The results of a chest X-ray conducted in March 1982 were normal. The Veteran complained of chest pains later that month, and was diagnosed with atypical chest pains, etiology unknown, suspect splenic flexure syndrome or gas pain variant. Findings revealed no evidence of intrathoracic pathology/cardiopulmonary disease, but there was first degree atrioventricular (AV) block with no therapy indicated. During his August 1982 discharge examination, both lower extremities and feet were evaluated as normal. Heart examination showed bradycardia, but the electrocardiogram (ECG) was considered to be within normal limits. Private treatment records show that the Veteran was diagnosed with diabetes mellitus, type 2 and hypertension in 2004, more than 20 years after his discharge from service, and that he has been treated for coronary artery disease (CAD), hypertensive heart disease and bilateral deep venous insufficiency of the lower extremities since 2007. In accordance with the Board's October 2011 remand, the Veteran was afforded a VA examination in September 2012. The examiner noted that the Veteran had a diagnosis of CAD and hypertensive heart disease. He also noted that the Veteran was diagnosed with hypertension and diabetes mellitus, type 2 in 2004, and indicated that the Veteran's coronary artery disease was caused by his diabetes mellitus, and that his hypertensive heart disease was caused by his hypertension. The examiner opined that the Veteran's claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In rendering his opinion, he noted that the Veteran was found to have normal blood pressure readings in 1968, 1978, 1979 and 1982, and as such, his current hypertensive cardiovascular disease was less likely as not related to service. With regard to both the hypertensive cardiovascular disease and the CAD, he noted that although findings of bradycardia were reported on physical examination in 1982, the ECG was within normal limits, and the finding of bradycardia on auscultation was transient and was likely a normal variant since his ECG did not show any abnormalities. The September 2012 VA examiner also noted that the complaints of chest pains in March 1982 was not from any cardiopulmonary disease and the finding of first degree AV block was absent on discharge examination in August 1982. There is no evidence otherwise linking the current disability to service. The Veteran has not reported a continuity of symptomatology beginning in service and there is no other evidence, VA or private, which indicates that the Veteran's heart disease may be related to his active military service. With regard to the years-long evidentiary gap in this case between active service and the earliest manifestations of coronary artery disease/hypertensive cardiovascular disease, the Board notes that a prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board must consider all the evidence, including the availability of medical records, the nature and course of the disease or disability, the amount of time that elapsed since military service, and any other relevant facts in considering a claim for service connection. Id. cf. Dambach v. Gober, 223 F.3d 1376, 1380-81 (Fed. Cir. 2000) (holding that the absence of medical records during combat conditions does not establish absence of disability and thus suggesting that the absence of medical evidence may establish the absence of disability in other circumstances). Thus, when appropriate, the Board may consider the absence of evidence when engaging in a fact finding role. See Jordan v. Principi, 17 Vet. App. 261 (2003) (Steinberg, J., writing separately) (noting that the absence of evidence may be considered as one factor in rebutting the aggravation part of the section 1111 presumption of soundness). The presumption of service connection for chronic diseases diagnosed within one year following discharge from active duty is also inapplicable to this case because the evidence demonstrates that the disorder was initially manifested many years after the Veteran's discharge from service. The Veteran is competent to report the symptoms of his disability; however, it would require medical expertise to say that the current coronary artery disease/hypertensive cardiovascular disease, identified long after service, is the result of a disease or injury in service. The Veteran, as a layperson, is not qualified to render an opinion concerning the medical cause of his heart disease. 38 C.F.R. § 3.159(a)(1),(2) (2012). For the reasons and basis stated above, the Board finds that service connection for coronary artery disease/hypertensive cardiovascular disease on a direct or presumptive basis is not warranted. As noted above, the Veteran also contends that his coronary artery disease/hypertensive cardiovascular disease is a secondary complication of his diabetes mellitus, which he claims developed as a result of his exposure to Agent Orange. The Veteran mainly asserts that he served in the coastal waters of the Republic of Vietnam during the Vietnam Era. VA currently recognizes that coronary artery disease is associated with exposure to herbicides. See 38 C.F.R. § 3.309(e). Exposure to Agent Orange will be presumed when it is shown that there is service in the Republic of Vietnam between January 9, 1962 and May 7, 1975. 38 U.S.C.A. § 1116 (West 2002). 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). In Haas v. Peake, 525 F. 3d 1168 (Fed. Cir 2008), cert. denied Haas v. Peake, cert. denied 129 S. Ct. 1002 (2009), the issue was whether it was necessary to set foot within the land borders of Vietnam during the operative period in order to enjoy the presumption of exposure to Agent Orange under 38 U.S.C.A. § 1116 and 38 C.F.R. § 3.307(a)(6)(iii). The Federal Circuit decided that Veterans who served offshore of Vietnam could only enjoy the presumption of exposure to Agent Orange if they actually set foot within the land borders in Vietnam during the operative period. Therefore, if and only if a Veteran set foot within the land borders in Vietnam during the operative period, he or she is be presumed to have been exposed to herbicide agents. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a)(6)(iii) (2012); Haas. If the Veteran can show that he set foot within the land borders in the Republic of Vietnam during his service in Vietnam, or was otherwise exposed to Agent Orange during service, he is entitled to the presumption of service connection for his coronary artery disease/hypertensive cardiovascular disease based on Agent Orange exposure, under 38 U.S.C.A. § 1116 and 38 C.F.R. §§ 3.307, 3.309. Unfortunately, the preponderance of the evidence indicates that the Veteran did not set foot on land in Vietnam during his Vietnam service and that he was not otherwise exposed to Agent Orange during service. The Veteran originally asserted in September 2007 merely that he served on ships anchored in the shores in Vietnam. He mentioned his duty stations aboard ships in May 2008, making no mention of having set foot on land in Vietnam. He mentioned in May 2008 that he had been on a ship which supplied ships that were operating around Vietnam, and that he had been anchored off the coast of Vietnam while on another ship. He also mentioned going from aircraft carrier to aircraft carrier in the western Pacific via helicopter. A letter written by a private physician on his behalf in December 2007 notes that the Veteran had advised of having been on several service ships that came close to the coast of Vietnam during the Vietnam War. Also, in August 2008, the Veteran expressed his hope that his service aboard several ships that sailed near the coastal waters of Vietnam would result in a favorable determination. After he was told about the outcome of the Haas case in June 2009, and of its requirement that one must be physically present within the land borders of Vietnam during service, he mentioned in August 2009 that ships he had been on during the Vietnam War had entered "the combat zone." A January 2010 statement from the Veteran is the first mention of the Veteran having set foot on land in Vietnam during the Vietnam Era. At that time, the Veteran indicated that sometime during the 1960's he had been on his way back from leave and stopped over at a Marine Base in Vietnam as he tried to catch a helicopter flight to take him to an aircraft carrier flagship. He indicated that he had stayed at the base for many hours and had even dined in the chow hall there. The RO asked him for more details in April 2010. Specifically, he was asked for the name of the ship he was on, the name of the ship he was headed to when he made a stopover in Vietnam, and a 60-day time range. The Veteran responded in July 2010 that he could not remember the name of the ship he had been on or was headed to when he stopped in Vietnam, and that he thought his stopover was in Chu Lai or Onthoi. He did not provide any meaningful timeframe information. In a November 2010 statement, he indicated that his stopover was at the Marine base in South Vietnam and that he had dined at its chow hall on his way back to his unit aboard its flagship. Based on the evidence, the Board does not find the Veteran's contention that he set foot in Vietnam during the Vietnam Era to be credible. Initially, the Veteran only mentioned service on ships off shore of Vietnam, emphasizing only that he had sailed near the coastal waters of Vietnam in August 2008. It was only after he was told that setting foot in Vietnam was needed for the presumption of service connection based on Agent Orange exposure to apply, that he provided the account of having set foot in Vietnam on a stopover. He has not been able to provide specifics regarding the alleged stopover, and has submitted no acceptable proof of it. The Board could accept his report if it found it to be credible. However, the Board finds that his report lacks credibility. The Board feels that if he had set foot on land in Vietnam during the Vietnam Era, as he subsequently claimed, he would have mentioned it earlier and that he likely would have provided some additional information as to when and how it happened. Unfortunately, service in the coastal waters of Vietnam is not in itself sufficient for the presumption of Agent Orange exposure to apply. Haas. The only other basis to grant the claim would be for the Veteran to show actual Agent Orange exposure in service. He has asserted that he served on ships in the coastal waters of Vietnam, that wounded Marines from Chu Lai came aboard his ship in the Coastal waters, and that his command directed the launching of planes from aircraft carriers to bomb enemy positions in Vietnam. However, he professes to have had no knowledge of Agent Orange at the time of his service and has not provided any evidence that he personally was exposed to Agent Orange during service. He has not indicated that he was physically in contact with anything or anybody that likely had Agent Orange on them. Accordingly, the Board finds the record to be without competent and credible evidence of actual Agent Orange exposure that would alternatively provide a basis to service connected the Veteran's disability. Since the preponderance of the evidence indicates that the Veteran did not set foot within the land borders in Vietnam, and was not otherwise exposed to Agent Orange, his coronary artery disease/hypertensive cardiovascular disease is not entitled to the presumption of service incurrence based on Agent Orange exposure or further medical development regarding whether any actual exposure was related to his CAD. Haas; 38 C.F.R. §§ 3.307, 3.309, 3.310. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not applicable to this claim. ORDER Service connection for coronary artery disease/hypertensive cardiovascular disease is denied. REMAND As noted above, the Veteran was afforded a VA examination in September 2012 to determine the etiology of his claimed bilateral deep venous insufficiency. The examiner noted that the Veteran started experiencing leg swelling in 2002 with feet debridement and an amputation of the left 5th toe. Venous duplex scan at that time showed deep venous insufficiency. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In rendering his opinion, he noted that the Veteran had a fracture of 2nd metatarsal bone of the left foot in 1978, during service, but aside from the left foot injury, he did not exhibit any bilateral leg or feet swelling during service, as evidenced by the normal feet and lower extremity examination in 1982. He also noted that the Veteran reported that his leg swelling began in the early 2000's, more than one year from the date of his discharge. The September 2012 VA examiner specifically concluded that "the absence of any bilateral leg swelling during active service makes the Veteran's current bilateral deep venous insufficiency less likely as not related to any in-service event, disease or injury." However, the Board notes that the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Additionally, the Board notes that as discussed above, the Veteran was noted to have bradycardia at the time of his service discharge examination in August 1982, which as the Board noted in its October 2011 remand, is possible evidence of bilateral venous insufficiency during service. The September 2012 VA examiner's opinion on the etiology of the deep venous insufficiency does not take this evidence into account. Once VA undertakes to provide an examination it is obligated to insure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). To be adequate, an examination must take into account an accurate history. Nieves-Rodriguez v. Nicholson, 22 Vet. App. 295 (2008). As the examiner did not consider all of the Veteran's history or complaints, his negative opinion is inadequate for rating purposes. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). VA regulations provide that where an examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes. 38 C.F.R. § 4.2 (2012). Where the Board makes a decision based on an examination report which does not contain sufficient detail, remand is required "for compliance with the duty to assist by conducting a thorough and contemporaneous medical examination." Goss v. Brown, 9 Vet. App. 109, 114 (1996); Stanton v. Brown, 5 Vet. App. 563, 569 (1993). Therefore, the Board believes that the Veteran should be afforded another VA examination to determine the nature and etiology of his current bilateral venous insufficiency. The appellant is hereby notified that it is his responsibility to report for the examination and to cooperate in the development of the case, and that the consequences of failure to report for a VA examination without good cause may include denial of the claim. See 38 C.F.R. §§ 3.158 and 3.655 (2012). Accordingly, the case is REMANDED for the following action: 1. The RO should schedule the Veteran for an appropriate VA examination by an examiner, other than the examiner who examiner the Veteran in September 2012, to address the nature and etiology of his bilateral deep venous insufficiency disabilities. The Veteran's claims folder must be made available to and reviewed by the examiner in conjunction with the examination. Based upon the examination results and a review of the claims folder, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or more probability) that any current bilateral deep venous insufficiency disability had its onset during active service or is related to any in-service event, disease, or injury, including the bradycardia shown in August 1982. The examiner should provide a rationale for the opinion. The examiner is advised that the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. A complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided. 2. After completing the requested action, and any additional notification and/or development deemed warranted, readjudicate the claim. If the benefit sought on appeal remains denied, furnish the Veteran and his representative an appropriate supplemental statement of the case containing notice of all relevant actions taken on the claim, to include a summary of the evidence and applicable law and regulations considered pertinent to the issue currently on appeal, and the claim should thereafter be returned to the Board if otherwise in order. 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). 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). ______________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs