Citation Nr: 1319722 Decision Date: 06/19/13 Archive Date: 06/27/13 DOCKET NO. 09-15 656 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Whether new and material evidence has been received to reopen a previously denied claim for service connection for mitral valve prolapse. 2. Entitlement to service connection for chronic obstructive pulmonary disorder (COPD). 3. Entitlement to service connection for hypertension. 4. Entitlement to service connection for osteoporosis. 5. Entitlement to service connection for depression. 6. Entitlement to service connetion for lumbar spine disorder. 7. Entitlement to service connection for bilateral leg condition, to include as secondary to lumbar spine disorder. 8. Entitlement to service connection for syncopal attacks. 9. Entitlement to service connection for dizziness. 10. Entitlement to service connection for mitral valve prolapses. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD J. Murray, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from May 1980 to May 1983. These matters come on appeal to the Board of Veterans' Appeals (Board) from rating decisions dated in October 1983 and March 2008 of the Department of Veterans Affairs (VA). Initially, the Board notes that the Regional Office (RO) in Montgomery, Alabama, identified an October 1983 rating decision as a final decision (which denied entitlement to service connection for syncopal attacks that was originally claimed as dizziness, blackouts, and loss of vision). However, the record reflects that the Veteran filed a timely notice of disagreement as to that denial in August 1984, but the RO did not issue a statement of the case (SOC) and no other action was taken. The claim remains pending until a SOC is issued. See 38 C.F.R. §§ 19.26, 19.29 (2012). Here, a SOC was not issued until March 2009, after the RO received additional correspondence from the Veteran in April 2005, which the RO interpreted as a claim to reopen a previously denied claim. After the March 2009 SOC was issued, the Veteran filed a timely substantive appeal; thus perfecting the instant appeal for syncopal attacks and dizziness. In a June 2007 rating decision, the RO declined to reopen a previously denied claim for mitral valve prolapse as well as denied the Veteran's other claims for service connection. The Veteran submitted a statement in October 2007 in which he stated that he had additional VA treatment records that should be considered in conjunction with his petition to reopen and his service connection claims. The Veteran's claims remained pending. See 38 C.F.R. § 3.156(b) (New and material evidence received prior to the expiration of the appeal period, or prior to the appellate decision if a timely appeal has been filed will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period). The RO readjudicated those claims in a March 2008 rating decision to which the Veteran perfected this appeal. The Veteran initially filed a claim for service connection for anxiety and depression. In the specific context of mental disorders, the United States Court of Appeals for Veterans' Claims (the Court) has held that "when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled." See Clemons v. Shinseki, 23 Vet. App. 1 (2009). This case clarifies the appropriate posture for claims such as the Veteran's, where multiple mental disorders, and/or disparate diagnoses are involved. Accordingly, the Board is expanding the issue on appeal at this time, as reflected on the title page of this decision, and will consider whether service connection may be awarded for an acquired psychiatric disorder, to include depression and anxiety, as instructed by the Court in Clemons. The record shows that the Veteran failed to report for an April 2012 scheduled hearing before a member of the Board without good cause. Therefore, the hearing request is deemed to have been withdrawn. 38 C.F.R. § 20.704 (2012). In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file has been considered in conjunction with this decision. The issues of entitlement to service connection for lumbar spine disorder, bilateral leg disorder, mitral valve prolapse, anxiety with associated syncopal attacks, dizziness and depression 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. In a 1988 rating decision, the RO denied the Veteran's claim for entitlement to service connection for heart condition, claimed as mitral valve prolapse, because the evidence of record failed to demonstrate a current disorder that was incurred in or related to his period of service. The Veteran was notified of this decision in September 1988, but he did not appeal that decision. 2. The additional evidence associated with the claims folder subsequent to the RO's 1988 rating decision relates to an unestablished fact (a current diagnosis of mitral valve prolapse) that is necessary to substantiate the claim, and raises a reasonable possibility of substantiating that claim. 3. The Veteran's hypertension was not first manifested in service or for more than two decades after his separation from service, and the preponderance of the medical evidence is against a finding that his hypertension is otherwise related to his period of service. 4. The Veteran's COPD was not first manifested in service or for more than two decades after his separation from service, and the preponderance of the medical evidence is against a finding that his COPD is otherwise related to his period of service. 5. The Veteran's osteoporosis was not first manifested in service or for more than two decades after his separation from service, and the preponderance of the medical evidence is against a finding that his osteoporosis is otherwise related to his period of service. CONCLUSIONS OF LAW 1. The 1988 rating decision which denied the Veteran's service connection claim for mitral valve prolapse is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.104, 20.1103 (2012). 2. Since the 1988 rating decision, new and material evidence has been received with respect to the Veteran's claim of entitlement to service connection for mitral valve prolapse. Therefore, the claim is reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 3. The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C.A. §§ 1101, 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 4. The criteria for entitlement to service connection for COPD have not been met. 38 U.S.C.A. §§ 1101, 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 5. The criteria for entitlement to service connection for osteoporosis have not been met. 38 U.S.C.A. §§ 1101, 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). VA is required to notify the claimant of the information and evidence not of record that is necessary to substantiate the claim. VA will inform the claimant, which information and evidence VA will seek to provide, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159(b). VA must provide such notice to the claimant prior to an initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (AOJ), even if the adjudication occurred prior to the enactment of the VCAA. See Pelegrini v. Principi, 18 Vet. App. 112, 119-120(2004). These VCAA notice requirements apply to all five elements of a service-connection claim: veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specific to requests to reopen a previously-denied claim for service connection, VA must provide notice that describes the basis for the previous denial, as well as the reopening criteria and the criteria for establishing the underlying claim for service connection found to be unsubstantiated in the previous denial. See Kent v. Nicholson, 20 Vet. App. 1 (2006). Here, VA sent notice letters to the Veteran in June 2005, October 2005, December 2005, April 2007, and December 2007, in which the Veteran was informed about the evidence required to substantiate the claims and his and VA's respective duties for obtaining evidence. In the December 2007, VA notified the Veteran of what constituted "new" and "material" evidence pertaining to his claim for service connection for mitral valve prolapse. See Kent, 20 Vet. App. at 9. In the April 2006 letter, VA also informed the Veteran on how it determines the effective date for the award of benefits if service connection is to be awarded consistent with the holding in Dingess. These notices were provided to the Veteran prior to the re-adjudication of his claims in the March 2008 rating decision. See Prickett v. Nicholson, 20 Vet. App. 370, 376-77 (2006); Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). On review of the claim file, it appears that the Veteran has been provided with sufficient notification, and he has been given every opportunity to submit evidence and argument in support of his claims and to respond to VA notices. Under these circumstances, the Board has determined that the notification requirements of the VCAA have been satisfied. As to VA's duty to assist the appellant with the obtaining evidence necessary to substantiate a claim, under 38 U.S.C.A. § 5103A, in this case VA has associated with the record copies of the Veteran's service treatment records, including records from Troup Medical Clinic 5, as well as the available identified post-service medical records and various statements submitted by the Veteran. The Board acknowledges that not all of the post-service treatment records identified by the Veteran were available. Negative responses for records were obtained from Long Island Jewish Memorial Hospital, Doctor's Hospital, Martin Army Community Hospital, Jackson State Prison, and New York Hospital Flushings Queens. While other treatment records were identified by the Veteran in various statements, the Veteran failed to provide completed authorizations to allow VA to attempt to obtain additional despite the RO's requests to do so. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (stating that VA's duty to assist in developing the pertinent facts and evidence in connection with a claim is not a one-way street, and the Veteran has a responsibility to cooperate in such development). The Board acknowledges that VA has not afforded the Veteran with VA examinations relating to his claims for service connection. However, the Board finds that such examinations are not necessary to render a decision under the circumstances of this case. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C.A. § 5103A(d)(2), 38 C.F.R. § 3.159(c)(4)(i). Although there are current diagnoses of hypertension, COPD, and osteoporosis, post-service treatment records show that the Veteran was not first diagnosed or treated for his current disorders until two decades after his discharge. Additionally, there is no competent evidence that indicates that there "may" be a relation between the Veteran's current diagnosed disorder and his service. While the Veteran believes the current diagnosed disorders are related to service, he is not competent to testify to such matter because this question requires specialized knowledge, training, or experience due to the complexity of the internal body systems. See Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). Moreover, the Veteran has not asserted that he has had continuity of COPD or osteoporosis since his period of service. While the Veteran does assert that he was informed that he had hypertension during his period of service, none of his service treatment records reflects treatment or diagnosis of hypertension. Rather, the report of an August 1983 VA general medical examination report shows an impression of probable hypotension, which suggests that the Veteran did not suffer from elevated blood pressure within the first year after his separation from service. Simply stated, referral of the claims for examination or obtainment of medical opinions on the matters of service connection under the circumstances here presented would be an unnecessary act. 38 U.S.C.A. § 5103A(a)(2); see also McLendon, 20 Vet. App. 79. Accordingly, the Board finds that no prejudice to the Veteran will result from an adjudication of the matter on appeal. For the foregoing reasons, the Board therefore finds that VA has satisfied its duty to notify and its duty to assist pursuant to the VCAA. See 38 U.S.C.A. §§ 5102 and 5103; 38 C.F.R. §§ 3.159(b), 20.1102; Pelegrini, supra; Quartuccio v. Principi, 16 Vet. App. 183 (2002). Petition Reopen Previously Denied Claim The Veteran seeks entitlement to service connection for mitral valve prolapse. Implicit in this claim is the contention that new and material evidence which is sufficient to reopen previously disallowed claims of service connection for mitral valve prolapose has been received. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. In general, VA rating decisions or Board decisions that are not timely appealed are final. See 38 U.S.C.A. § 7105; 38 C.F.R. §§ 20.1100, 20.1103. Pursuant to 38 U.S.C.A. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. New evidence is defined as evidence not previously submitted to agency decision-makers. 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 of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. See 38 C.F.R. § 3.156(a). An adjudicator must follow a two-step process in evaluating a previously denied claim. First, the adjudicator must determine whether the evidence added to the record since the last final decision is new and material. If new and material evidence is presented or secured with respect to a claim that has been finally denied, the claim will be reopened and decided upon the merits. Once it has been determined that a claimant has produced new and material evidence, the adjudicator must evaluate the merits of the claim in light of all the evidence, both new and old, after ensuring that the VA's statutory duty to assist the appellant in the development of her claim has been fulfilled. See 38 U.S.C.A. § 5108 (West 2002); Elkins v. West, 12 Vet. App. 209 (1999); Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999). The Court has recently stated that the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110 (2010). Moreover, in determining whether this low threshold is met, consideration need not be limited to consideration of whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is presumed. See Justus v. Principi, 3 Vet. App. 510, 513(1992). Here, the RO originally denied the Veteran's claim for service connection for mitral valve prolapse in a 1988 rating decision, because the record failed to demonstrate a current diagnosed disorder that was incurred in or related to his period of service. The Veteran was notified of the RO's denial in a September 1988 letter. The Veteran did not appeal, and the RO's decision became final. 38 C.F.R. §§ 3.104, 20.1103. At the time of the 1988 rating decision, the evidence of record included the Veteran's service treatment records, August 2008 VA general medical and neurologic examination reports, and the Veteran's statement in support of his case. The additional evidence received since the 1988 rating decision includes VA and private treatment records that reflect a current diagnosis of mitral valve prolapse as well as the Veteran's reported history of symptomatology that dated back to his period of service. These additional VA and private treatment records received since the RO's 1988 rating decision relate to an unestablished fact (whether the Veteran's anal fissure had an onset during service), and that is necessary to substantiate each of the claims. Further, the additional records are neither cumulative nor redundant, and that they raise a reasonable possibility of substantiating the claims. Based on the foregoing, the Board finds that new and material evidence has been received that meets the requirements to reopen the claim. On that basis, the claim for service connection of mitral valve prolapse is reopened. 38 C.F.R. § 3.156. The Board notes in passing that although there may be of record new and material evidence sufficient to reopen the Veteran's mitral valve prolapse, this does not mean that the claim must be allowed based on such evidence. In Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998), the United States Court of Appeals for the Federal Circuit noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a Veteran's injury or disability, even where it would not be enough to convince the Board to grant a claim. Service Connection 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; 38 C.F.R. § 3.303(a). 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). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. See 38 C.F.R. § 3.303(b). The chronicity provision of 38 U.S.C.A. § 3.303(b) is applicable where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has such condition. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Certain chronic diseases, although not shown in service, may be presumed to have incurred in or aggravated by service if they become manifested to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. To prevail on the issue of service connection, there must be (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 current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a); Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). If there is at least an approximate balance of positive and negative evidence regarding any issue material to the claim, the claimant shall be given the benefit of the doubt in resolving each such issue. 38 U.S.C.A. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. §§ 3.102. On the other hand, if the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. In this case, the Veteran seeks entitlement to service connection for hypertension, COPD, and osteoporosis. He essentially asserts that his current diagnosed disorders are related to his period of service. As noted above, in order to establish service connection for the claimed disorder, there must be (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus or relationship between the two. See Hickson v. West, 12 Vet. App. at 253. With respect to element (1), the medical evidence of record demonstrates that the Veteran has current diagnoses of hypertension, COPD, and osteoporosis. See a September 2003 private chest x-ray report, a September 2005 private bone scan report, as well as VA treatment records dated from 2003 to 2007. Based on the above, it is clear that element (1), current disability, is satisfied for each claim. The Board will now turn to whether the evidence of record supports element (2), in-service disease or injury. With respect to the Veteran's COPD and osteoporosis claims, the service treatment records do not document any treatment or complaints involving the respiratory or bone-related problems, let alone findings indicative of COPD or osteoporosis. At the time of the Veteran's April 1983 examination prior to separation, his lungs and muscularskelatal systems were evaluated as normal, and his chest x-ray was negative. No evidence of record demonstrates that COPD or osteoporosis, had its onset within the Veteran's first post-service year. Rather, the first diagnostic evidence of COPD comes from a September 2003 private chest x-ray report and the first diagnostic evidence of osteoporosis comes from a September 2005 private bone scan report. The first diagnostic evidence for both disorders comes more than two decades after the Veteran's separation from service. As such, COPD and osteoporosis were not diseases that were incurred during the Veteran's period of service, and osteoporosis may not be presumed under the provision of 38 C.F.R. § 3.307 and 3.309(a). While the service treatment records do document the Veteran's complaints of chest pain as well reflect findings of a heart murmur, there is no indication in those records that the Veteran was felt to have hypertension based on his symptomatology. Rather, his symptomatology (chest pain, dizziness, and heart palpitations) were thought to be associated with possible heart murmur or anxiety attacks with syncope. Moreover, none of the recorded in-service blood pressure readings (BPRs) is suggestive of hypertension as defined by VA. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1 (VA regulations provide that the term hypertension means that the diastolic blood pressure is predominantly 90mm, or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm, or greater, with a diastolic blood pressure of less than 90mm.) At the time of the Veteran's April 1983 examination prior to separation, his heart and cardiovascular system were evaluated as normal, and his blood pressure reading was 98/58. The associated report of medical history shows the Veteran complained of dizziness, fainting spells, chest pain, heart palpations, nervousness, and loss of consciousness, but he denied having experienced heart trouble or high blood pressure. Shortly after the Veteran's separation from service, the Veteran was afforded an August 1983 VA general medical and neurologic examination in conjunction with a claim for service connection for a disorder manifested by dizziness, loss of vision, and blackouts. The general medical VA examination report shows that the Veteran's BPRs were 84/60, 92/68, and 90/70. An impression of possible hypotension was given. The available subsequent post-service treatment records do not show that the Veteran was treated for hypertension until 2006. The Board notes that a review of the Veteran's VA treatment record dated in October 2005 does not reflect that the Veteran's medication included treatment for high blood pressure, however, as of August 2006, the VA treatment records do reflect medication for high blood pressure. The evidence of record does not show that the Veteran's hypertension was first incurred during his period of service or until more than two decades beyond the one year presumptive period for hypertension. 38 C.F.R. §§ 3.303, 3.307, 3.309. The competent evidence of record does not demonstrate that the Veteran's hypertension, COPD or osteoporosis had an onset during his periods of service or within the first year after his separation from service. Element (2), an in-service injujry or disease, has not been satisfied. For purposes of completeness, the Board will also discuss element (3), nexus or relationship. Here, there is no favorable medical nexus opinion of record that supports medical links between the current diagnoses hypertension, COPD, and/or osteoporosis and the Veteran's period of service. Moreover, an examination to obtain such medical nexus opinion is not necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A(d)(2). There is no objective medical evidence indicative of hypertension, COPD or osteoporosis in service or at separation, no evidence of continuity of treatment since service, no evidence of treatment for all three of the conditions until two decade after service, and no medical evidence linking the currently diagnosed disorder directly to service. A VA examination is not called for in this matter. See McClendon, 20 Vet. App. 79. As noted above in the legal criteria above, under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third service-connection element for certain chronic diseases, including arthritis, is through a demonstration of continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013);see also Savage, 10 Vet. App. at 495-97. However, the Veteran has not asserted at point during the appeal period that he has experienced symptoms of hypertension or osteoporosis continuously since his period of service. Rather, he simply asserted that he was first diagnosed with hypertension during his period of service; however, as discussed above, none of the service treatment records demonstrates a diagnosis of hypertension or reflects BPRs indictative of high blood pressure. Notably, hypertension is a disorder that is demonstrated through the results of blood pressure testing, and the Board observes that the criteria of 38 C.F.R. § 4.104, Diagnostic Code 7101 (hypertension) do not contemplate any symptoms that would be capable of lay observation. See 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, element (2), in-service disease or injury, and element (3), a nexus or relationship between the current diagnosed disorder and injury in service, have not been satisfied, and the Veteran's service-connection claims fails on these bases. The benefit of the doubt rule is not for application because the evidence is not in relative equipoise. ORDER New and material evidence having been received, the previously denied claim for entitlement to service connection for mitral valve prolapse, is reopened. Entitlement to service connection for hypertension is denied. Entitlement to service connection for chronic obstructive pulmonary disorder (COPD) is denied. Entitlement to service connection for osteoporosis is denied. REMAND Unfortunately, a remand is required in this case. 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 claims so that he is afforded every possible consideration. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. VA's duty to assist includes providing a medical examination when it is necessary to make a decision on a claim. See Id. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or symptoms of disability, (2) establishes that the veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4) (2012); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third prong may be satisfied by lay evidence of continuity or equivocal or non-specific medical evidence). Mitral Valve Prolapse, Anxiety with Syncopal Attacks, and Dizziness As noted above, with regard to the claim for service connection for mitral valve prolapse, VA has received additional evidence which is sufficient to reopen the Veteran's claim; however, additional development is necessary prior to adjudication of the appeal on the merits. Specifically, a remand is required to provide the Veteran with a VA examination. The Veteran's claims for service connection for anxiety with syncopal attacks and dizziness are intertwined with his mitral valve prolapse claim, given that he has asserted that his in-service symptomatology of dizziness and syncopal attacks mark the onset of his mitral valve prolapse. Here, the Veteran's service treatment records show that shortly after his entrance into service, the Veteran presented for emergency treatment with complaints of chest pain and blackouts. He reported that he had a history of episodes with dizziness, loss of conscious, chest pain and tingling within the past two years. It was thought that his symptoms were associated with possible heart murmur or anxiety attacks with syncope. Subsequent service treatment records are replete with similar episodes of chest pain, dizziness, fainting spells, and heart palpitations; however, it does not appear that any clear etiology was associated with the Veteran's episodic symptomatology. Shortly after the Veteran's separation from service, he was provided with VA general medical and neurologic examinations. The VA examination report show that the Veteran complained of recurrent episodes of chest pain, lightheadedness, blurred vision. The Veteran reported that these episodes had an onset during his period of service and were related to his activities. Clinical evaluation revealed that the Veteran had hypotension of an unknown etiology with premature auricular contractions. His neurologic evaluation was normal and the Veteran was diagnosed with syncopal attacks, claimed. The Veteran subsequently reported that he was informed by his medical providers that his episodic symptomatology was associated with a diagnosis of mitral valve prolapse, although those private treatment records have not been associated with the claim folders. The current VA and private medical evidence of record do reveal that the Veteran has a history of mitral valve prolapse. Given the Veteran's assertion that the episodic symptomatology in service marked the onset of his mitral valve prolapse, the Board finds that a VA examination is needed to address the Veteran's contentions. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Thus, on remand, the Veteran should be provided with a new VA eye examination in conjunction with his claim. Lumbar Spine and Bilateral Leg Disorders The Veteran contends that his lumbar spine disorder is related to his period of service. A February 1982 service treatment records shows that the Veteran complained of back pain from an injured he sustained after falling on ice. Clinical evaluation revealed no visual physical impairment and the Veteran was assessed with bruised muscle. A later February 1982 service treatment record shows that the Veteran again presented with complaints of back pain and he was assessed with poor body mechanics and slight pain on range of motion. Subsequent records do not show that the Veteran sought any further treatment for complaints of back pain. On his April 1984 report of medical history, the Veteran denied that he had experienced recurrent back problems. The Veteran reports that he has severe back pain with radiating pain and numbness into his legs. The medical evidence shows that the Veteran has degenerative disc disease of the lumbar spine with secondary lumbar radiculopathy. Although he complained of continuous back pain since service, it does not appear that he began to seek treatment for his back and knee problems for almost two decades after his separation from service. There is no VA examination of record with respect to the Veteran's claimed disorders. Since there is evidence of in-service treatment for problems involving the Veteran's low back as well as the lay evidence of a continuity of symptoms since active service, the Board finds that a medical examination is needed prior to adjudication of the claims on appeal. See 38 C.F.R. § 3.159(c)(4); McLendon, 20 Vet. App. at 83-86. On remand, the RO should schedule the Veteran for appropriate VA examination including an opinion to address the questions regarding the nature, onset and etiology of his claimed lumbar spine and bilateral leg disorders. Acquired Psychiatric Disorder, to include Depression The Veteran's service treatment records show that he sought treatment for complaints of mental health symptoms. A June 1980 consultation request note show that the Veteran had an episode of hyperventilation and he reported a history of nervousness and insomnia. A subsequent treatment note indicates that the Veteran had an anxiety attack with associated syncopal attacks. The Veteran's April 1983 examination report shows that the Veteran received a normal psychiatric evaluation, despite his complaints of possible nervous troubles on his associated report of medical history. He denied any symptoms of depression or excessive worry. Post-service treatment records reflect various diagnoses of psychiatric disorders, including mood disorder, adjustment disorder, depression, and schizophrenia. Given the in-service complaints of mental health symptoms as well as the Veteran's current diagnoses of various psychiatric disorders, the Board finds that the Veteran should be afforded a VA psychiatric examination to determine the nature and etiology of any acquired psychiatric disorder. See 38 C.F.R. § 3.159(c)(4); McLendon, 20 Vet. App. at 83-86. In addition, the Board notes that in-service mental health treatment records are maintained by the military or civilian treating facility - they are not stored with the traditional service treatment records. See M21-1MR, Part IV, subpart ii, 1.D.14.a. Given that the Veteran was referred for a mental health consultation, but the records of any subsequent mental health consultations have not been associated with the claims folder, suggests that there may be outstanding service mental health treatment records. Prior to any examination, with the Veteran's assistance, the RO/AM should obtain any outstanding records of pertinent private and VA treatment. Accordingly, the case is REMANDED for the following action: 1. Contact all the appropriate facilities to request any outstanding service treatment records, including any mental health treatment, from the Veteran's periods of active duty service, and associate them with the claims. 2. By appropriate means, and with any necessary assistance from the Veteran, the RO/AMC should seek to identify and to obtain any outstanding records of pertinent VA and private medical treatment that are not yet on file. 3. Schedule the Veteran for a VA examination by an appropriate specialist to determine the current natures and etiologies of the claimed mitral valve prolapse, anxiety with syncopal, and dizziness disorders found to be present. The claims folder and a copy of this remand are to be made available to and reviewed by the examiner in connection with the examination. The examination report is to contain a notation that the examiner reviewed the claims file. The examination is to include a review of the Veteran's history and current complaints, and any tests deemed necessary. Based on a review of the record and the clinical findings from examination, the examiner should provide opinions on the following. a). Is it at least as likely as not (50 percent or greater probability) that the Veteran's current diagnosed mitral valve prolapse was originally manifested by the episodic symptoms of chest pain, dizziness, fainting spells, and heart palpitations recorded in the service treatment records? Or is the Veteran's mitral valve prolapse otherwise related to his period of service? b). If the Veteran's in-service episodic symptoms do not mark the onset of his mitral valve prolapse, does the Veteran have any other current diagnosed disorder manifested by symptoms of dizziness, anxiety, and/or syncopal attacks. If so, please, specify the diagnosis (or diagnoses) and indicate whether it is at least as likely as not that such disabilities had an onset in service or are otherwise related to the Veteran's period of service? c). Does the evidence of record clearly and unmistakably show that the Veteran's mitral valve prolapse (or any other diagnosed disorder manifested by the episodic symptoms) existed prior to his entrance into active duty military service and, if so, whether it there is clear and unmistakable evidence that such diagnosed disorder was NOT aggravated during active military service? A complete rationale must be given for any opinion expressed, and the foundation for all conclusions should be set forth. If the examiner is unable to provide any opinion requested, then he or she must state so and why. 4. Schedule the Veteran for a VA examination by an appropriate specialist to determine the current natures and etiologies of the claimed lumbar spine and bilateral leg disorders found to be present. The claims folder and a copy of this remand are to be made available to and reviewed by the examiner in connection with the examination. The examination report is to contain a notation that the examiner reviewed the claims file. The examination is to include a review of the Veteran's history and current complaints, as well a comprehensive evaluation of his lumbar spine and legs and any tests deemed necessary. Based on a review of the record and the clinical findings from examination, the examiner should provide opinions on the following. a). Identify the nature of the Veteran's lumbar spine and bilateral leg disorders. (Please specify the diagnosis (or diagnoses).) b. For any diagnosed lumbar spine disorder, provide an opinion on whether it is at least as likely as not (50 percent or greater probability): (i) that such condition had its onset during the Veteran's period of active duty; or, (ii) that such disorder is related to or was otherwise caused by any injury that occurred during service? In doing so, the examiner should consider the inservice treatment and various assessments for back problems. c. For any diagnosed leg disorder, provide an opinion on whether it is at least as likely as not (50 percent or greater probability): (i) that such condition had its onset during the Veteran's period of active duty; or, (ii) that such disorder is related to or was otherwise caused by any injury that occurred during service, to include as proximately caused by his any in-service lumbar spine problems? A complete rationale must be given for any opinion expressed, and the foundation for all conclusions should be set forth. If the examiner is unable to provide any opinion requested, then he or she must state so and why. 5. Schedule the Veteran for a VA psychiatric examination, with an appropriate specialist, to determine the nature and etiology of any acquired psychiatric disorder. The claims folder must be provided to and reviewed by the examiner in conjunction with the examination. All indicated tests and studies should be performed, and all findings should be set forth in detail. The examiner should review the claims files prior to completing the examination report. Based on the review of the claims files and examination of the Veteran, the examiner should identify: a). Identify the nature of the Veteran's current acquired psychiatric disorders. (Please specify the diagnosis (or diagnoses).) b). Is it at least as likely as not that any of the Veteran's current diagnosed acquired psychiatric disorders was incurred in or is otherwise etiologically related to service. In doing so, the examiner should consider the in-service complaints and treatment. A complete explanation must be given for any opinion expressed, and the foundation for all conclusions should be set forth. The report of the examination should be associated with the claims file. 6. Thereafter, review the claims file 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. If the report does not include adequate responses to the specific opinions requested, it must be returned to the examiner for corrective action. 7. After completion of the above and any additional notice or development deemed necessary, re-adjudicate the claims remaining on appeal. If any determination remains unfavorable to the Veteran, he and his representative should be provided with a supplemental SOC and be afforded an opportunity to respond before the case is returned to the Board for further appellate review, 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). ______________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs