Citation Nr: 1319818	
Decision Date: 06/19/13    Archive Date: 06/27/13

DOCKET NO.  10-32 040	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Seattle, Washington


THE ISSUES

1.  Entitlement to an initial rating greater than 10 percent for bilateral hearing loss.

2.  Entitlement to service connection for arthritis of both hands, including as due to cold exposure.

3.  Entitlement to service connection for arthritis of both knees, including as due to cold exposure.

4.  Entitlement to service connection for skin cancer at multiple sites on the body, including as due to cold exposure.

5.  Entitlement to service connection for hypertension, including as due to cold exposure.

6.  Entitlement to service connection for a blood circulation disorder, including as due to cold exposure.

7.  Entitlement to service connection for vertigo, including as due to cold exposure.


WITNESSES AT HEARING ON APPEAL

The Veteran, G.H., and R.E.


ATTORNEY FOR THE BOARD

Michael T. Osborne, Counsel


INTRODUCTION

The Veteran had active service from February 1955 to December 1958.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington, in which the RO granted, in pertinent part, the Veteran's claim of service connection for bilateral hearing loss, assigning a 10 percent rating effective January 23, 2009, and also denied the Veteran's claims of service connection for arthritis of both hands, arthritis of both knees, skin cancer at multiple sites on the body (which was characterized as two separate service connection claims for skin cancer of the face and scalp and skin cancer of the torso, bilateral upper extremities, and bilateral lower extremities), hypertension, a blood circulation disorder, and vertigo, each including as due to cold exposure.  A Travel Board hearing was held at the RO in July 2012 before the undersigned Veterans Law Judge and a copy of the hearing transcript has been added to the record.  Having reviewed the record evidence, including the Veteran's most recent VA skin diseases Disability Benefits Questionnaire (DBQ) and VA scar/disfigurement DBQ in September 2012, the Board finds that the separate service connection claims for skin cancer of the face and scalp and skin cancer of the torso, bilateral upper extremities, and bilateral lower extremities are characterized more appropriately as a single service connection claim for skin cancer at multiple sites on the body, including as due to cold exposure.

In August 2012, the Board remanded this matter to the RO via the Appeals Management Center (AMC) in Washington, DC, for additional development.  A review of the claims file shows that there has been substantial compliance with the Board's remand directives.  The Board directed that the RO/AMC obtain the Veteran's updated treatment records.  A review of the claims file shows that, in a telephone conversation with RO personnel in August 2012, the Veteran informed VA that all of his medical care was provided by VA.  The Veteran's VA outpatient treatment records subsequently were associated with his claims file and his Virtual VA claims file.  The Board also directed that the RO/AMC schedule the Veteran for VA examinations to determine the current nature and severity of his service-connected bilateral hearing loss and the nature and etiology of his other claimed disabilities.  These examinations occurred in September and October 2012.  See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002).

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 issue of entitlement to service connection for vertigo, including as due to cold exposure, is addressed in the REMAND portion of the decision below and is REMANDED again to the RO/AMC.  VA will notify the Veteran if further action is required on his part.


FINDINGS OF FACT

1.  The record evidence shows that the Veteran's service-connected bilateral hearing loss is, at worst, assigned a Roman numeral of IV for the left ear and IV for the right ear; this equates to a 10 percent rating under the Rating Schedule.

2.  The record evidence shows that the Veteran does not experience any condition which was caused by cold exposure.

3.  The record evidence shows that the Veteran's bilateral hand arthritis is due to work and genetic predisposition and is not related to active service or any incident of service, including as due to cold exposure.

4.  The record evidence shows that the Veteran's bilateral knee arthritis is not related to active service or any incident of service, including as due to cold exposure.

5.  The record evidence shows that the Veteran's hypertension is not related to active service or any incident of service, including as due to cold exposure.

6.  The record evidence shows that the Veteran does not experience any current disability due to skin cancer at multiple sites on his body or a blood circulation disorder that could be attributed to active service.


CONCLUSIONS OF LAW

1.  The criteria for an initial rating greater than 10 percent for bilateral hearing loss have not been met.  38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.385, 4.85, 4.86, Tables VI, VIA, VII, Diagnostic Code (DC) 6100 (2012).

2.  Arthritis of the bilateral hands was not incurred in or aggravated by active service, including as due to cold exposure, nor may it be presumed to have been incurred in service.  38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012).

3.  Arthritis of the bilateral knees was not incurred in or aggravated by active service, including as due to cold exposure nor may it be presumed to have been incurred in service.  38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012).

4.  Skin cancer at multiple sites on the body was not incurred in or aggravated by active service, including as due to cold exposure.  38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2012).

5.  Hypertension was not incurred in or aggravated by active service, including as due to cold exposure, nor may it be presumed to have been incurred in service.  38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012).

6.  A blood circulation disorder was not incurred in or aggravated by active service, including as due to cold exposure.  38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2012).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined.  The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim.  

In a letter issued in February 2009, VA notified the Veteran of the information and evidence needed to substantiate and complete his claims, including what part of that evidence he was to provide and what part VA would attempt to obtain for him.  See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002).  This letter informed the Veteran to submit medical evidence relating the claimed disabilities to active service and noted other types of evidence the Veteran could submit in support of his claims.  The Veteran also was informed of when and where to send the evidence.  After consideration of the contents of this letter, the Board finds that VA has satisfied substantially the requirement that the Veteran be advised to submit any additional information in support of his claims.  See Pelegrini v. Principi, 18 Vet. App. 112 (2004).  Additional notice of the five elements of a service-connection claim was provided in the February 2009 VCAA notice letter, as is now required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006).

The Veteran's higher initial rating claim for bilateral hearing loss is a "downstream" element of the RO's grant of service connection for this disability in the currently appealed rating decision.  For such downstream issues, notice under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159 is not required in cases where such notice was afforded for the originating issue of service connection.  See VAOPGCPREC 8-2003 (Dec. 22, 2003).  Courts have held that once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial.  Hartman v. Nicholson, 483 F.3d. 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007).  As discussed above, in February 2009, VA notified the Veteran of the information and evidence needed to substantiate and complete the service connection claim for bilateral hearing loss, including what part of that evidence he was to provide and what part VA would attempt to obtain for him.  See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 16 Vet. App. at 187.

As will be explained below in greater detail, the evidence does not support assigning a higher initial rating for the Veteran's service-connected bilateral hearing loss.  The evidence also does not support granting service connection for arthritis of the bilateral hands, arthritis of the bilateral knees, skin cancer at multiple sites on the body, hypertension, and a blood circulation disorder, each including as due to cold exposure.  Because the Veteran was fully informed of the evidence needed to substantiate these claims, any failure of the RO to notify the Veteran under the VCAA cannot be considered prejudicial.  See Bernard v. Brown, 4 Vet. App. 384, 394 (1993).  The Veteran also has had the opportunity to submit additional argument and evidence and to participate meaningfully in the adjudication process.  Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006).

With respect to the timing of the notice, the Board points out that the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits.  See Pelegrini v. Principi, 18 Vet. App. 112 (2004).  Here, the February 2009 VCAA notice letter was issued prior to the currently appealed rating decision issued in December 2009; thus, this notice was timely.  Because all of the currently appealed claims adjudicated in this decision are being denied, any question as to the appropriate disability rating or effective date is moot.  See Dingess, 19 Vet. App. at 473.  And any defect in the notices provided to the Veteran has not affected the fairness of the adjudication.  See Mayfield, 444 F.3d at 1328.

The Board is aware of the decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) in which the Court held that, for an increased-compensation claim, section § 5103(a) requires, at a minimum, VA notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life.  Relying on the informal guidance from VA's Office of General Counsel (OGC) and a VA Fast Letter issued in June 2008 (Fast Letter 08-16; June 2, 2008), the Board finds that Vazquez-Flores is not applicable to the Veteran's claim for a higher initial rating for bilateral hearing loss.  According to OGC, because this claim concerns an appeal from an initial rating decision, VCAA notice obligations are satisfied fully once service connection has been granted.  Any further notice and assistance requirements are covered by 38 U.S.C. §§ 5104(a), 7105(d)(1), and 5103A as part of the appeals process, upon the filing of a timely NOD with respect to the initial rating or effective date assigned following the grant of service connection.

In Dingess/Hartman, 19 Vet. App. at 473, the Court held that, in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled.  Id., at 490-91.  To the extent that Dingess requires more extensive notice as to potential downstream issues such as disability rating and effective date, because the currently appealed rating decision was fully favorable to the Veteran on the issue of service connection for bilateral hearing loss, and because the Veteran was fully informed of the evidence needed to substantiate this claim, the Board finds no prejudice to the Veteran in proceeding with the present decision.  See also Bernard v. Brown, 4 Vet. App. 384, 394 (1993).

The Board also finds that VA has complied with the VCAA's duty to assist by aiding the Veteran in obtaining evidence and affording him the opportunity to give testimony before the RO and the Board.  It appears that all known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise.  The Veteran's Virtual VA claims file has been reviewed.  The Veteran also does not contend, and the evidence does not show, that he is in receipt of Social Security Administration (SSA) disability benefits such that a remand to obtain his SSA records is required.

In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above regulation.  These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked.  Here, during the hearing, the VLJ noted the basis of the prior determination and noted the element of the claim that was lacking to substantiate the claim for benefits.  The VLJ specifically noted the issues as including a higher initial rating for bilateral hearing loss and service connection for arthritis of the bilateral hands, arthritis of the bilateral knees, skin cancer at multiple sites on the body, hypertension, and a blood circulation disorder, each including as due to cold exposure.  The VLJ then asked questions to ascertain whether the Veteran had submitted evidence in support of these claims.  In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claims.  He specifically asked the Veteran about any worsening of the service-connected bilateral hearing loss and any symptomatology experienced since service for arthritis of the bilateral hands, arthritis of the bilateral knees, skin cancer at multiple sites on the body, hypertension, and a blood circulation disorder. 

Moreover, the Veteran has not asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) nor identified any prejudice in the conduct of the Board hearing.  By contrast, the hearing focused on the element necessary to substantiate the claims and the Veteran, through his testimony, demonstrated that he had actual knowledge of the element necessary to substantiate his claims for benefits.  The VLJ asked questions to draw out the evidence which demonstrated worsening of the Veteran's service-connected bilateral hearing loss and demonstrated a link between the claimed disabilities and active service, the only elements of the claims in question.  As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that any error in notice provided during the Veteran's hearing constitutes harmless error.

The Veteran has been provided with VA examinations which address the contended causal relationship between the claimed disabilities and active service.  He also has been provided with VA examinations which address the current nature and severity of his service-connected bilateral hearing loss.  38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4) ; McLendon v. Nicholson, 20 Vet. App. 79 (2006).  Given that the pertinent medical history was noted by the examiners, these examination reports set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations.  Thus, the Board finds the examinations of record are adequate for rating purposes and additional examination is not necessary regarding the claims adjudicated in this decision.  See also 38 C.F.R. §§ 3.326, 3.327, 4.2.  In summary, VA has done everything reasonably possible to notify and to assist the Veteran and no further action is necessary to meet the requirements of the VCAA.

Higher Initial Rating for Bilateral Hearing Loss

The Veteran contends that his service-connected bilateral hearing loss is more disabling than currently evaluated.

In general, disability evaluations are assigned by applying a schedule of ratings that represent, as far as can be determined, the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1.  Separate diagnostic codes identify the various disabilities and the criteria that must be met for specific ratings.  The regulations require that, in evaluating a given disability, the disability be viewed in relation to its whole recorded history.  38 C.F.R. § 4.2; see Schafrath v. Derwinski, 1 Vet. App. 589 (1991).

Where, as in this case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time.  Separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings.  See Fenderson v. West, 12 Vet. App. 119 (1999).

The Veteran's service-connected bilateral hearing loss currently is evaluated as 10 percent disabling under 38 C.F.R. § 4.85, DC 6100.  See 38 C.F.R. § 4.85, DC 6100.  The Rating Schedule provides a table for ratings purposes (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment, established by a state-licensed audiologist including a controlled speech discrimination test (Maryland CNC), and based upon a combination of the percent of speech discrimination and the puretone threshold average which is the sum of the puretone thresholds at 1000, 2000, 3000 and 4000 Hertz, divided by four.  See 38 C.F.R. § 4.85.  To evaluate the degree of disability from defective hearing, the rating schedule establishes eleven auditory acuity levels designated from I for essentially normal acuity, through XI for profound deafness.  38 C.F.R. § 4.85, Tables VI, VII.

Table VII is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment of each ear.  The horizontal row represents the ear having the poorer hearing and the vertical column represents the ear having the better hearing.  Id.  Table VIA is used when the examiner certifies that the use of speech discrimination test is not appropriate because of language difficulties, inconsistent speech discrimination scores, etc., or when indicated under the provisions of 38 C.F.R. § 4.86.  38 C.F.R. § 4.85(c).

When the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral.  Each ear will be evaluated separately.  38 C.F.R. § 4.86(a).  When the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral.  That numeral will then be elevated to the next higher Roman numeral.  Each ear will be evaluated separately.  38 C.F.R. § 4.86(b).

A 10 percent rating is assigned where hearing in the better ear is II and hearing in the poorer ear is V through XI, where hearing in the better ear is III and hearing in the poorer ear is IV through VI, and where hearing in the better ear is IV and hearing in the poorer ear is V.  38 C.F.R. § 4.85, Table VII, DC 6100.  A higher 20 percent rating is assigned where hearing in the better ear is III and hearing in the poorer ear is VII through XI, where hearing in the better ear is IV, and hearing in the poorer ear is VI through VIII, or where hearing in the better ear is V and hearing in the poorer ear is V or VI.  Id.

The Court has held that the assignment of disability ratings for hearing impairment is to be derived by the mechanical application of the Rating Schedule to the numeric designations assigned after audiometry evaluations are rendered.  Lendenmann v. Principi, 3 Vet. App. 345 (1992).

Factual Background

The Veteran's service treatment records show that, at his enlistment physical examination in February 1955, he denied all relevant pre-service medical history.  Clinical evaluation was completely normal.  The Veteran's hearing was "15/15" (or within normal limits) bilaterally on whispered voice hearing test.

On the authorized audiological evaluation in August 1957, the Veteran's pure tone thresholds, in decibels, were as follows:




HERTZ



500
1000
2000
3000
4000
RIGHT
10
10
10
10
10
LEFT
10
10
10
10
10

On periodic physical examination in April 1958, clinical evaluation of the Veteran's ears was normal.  The Veteran's hearing was "15/15" (or within normal limits) bilaterally on whispered voice hearing test.  His pure tone thresholds, in decibels, were as follows:




HERTZ



500
1000
2000
3000
4000
RIGHT
10
10
10
10
10
LEFT
15
15
20
15
10

At his separation physical examination in December 1958, clinical evaluation of the Veteran's ears was normal.  The Veteran's hearing was "15/15" (or within normal limits) bilaterally on whispered voice hearing test.  His pure tone thresholds, in decibels, were as follows:




HERTZ



500
1000
2000
3000
4000
RIGHT
0
0
0
0
0
LEFT
0
0
0
0
20

The post-service evidence shows that, on VA outpatient treatment in February 2002, it was noted that the Veteran "has some degree of hearing loss for which he has hearing aids that he does not use.  He states that his hearing loss is not bad enough at this point to warrant hearing aid use."  Physical examination showed moderately retracted tympanic membranes bilaterally with patent external auditory canals with minimal cerumen and no evidence of fluid or masses in the middle ear.  The assessment included hearing loss.

On VA audiology examination in September 2009, his complaints included hearing loss since 1956.  "The claimant indicates that while carrying out his duties repairing radar and armament on the flight line, he was exposed to loud noise."  He had "difficulty hearing and understanding conversations."  He denied any post-service history of noise exposure.  Physical examination showed bilateral auricles within normal limits and normal external ears bilaterally.  The Veteran's pure tone thresholds, in decibels, were as follows:




HERTZ



500
1000
2000
3000
4000
RIGHT
45
45
35
75
80
LEFT
40
50
45
65
75

Speech audiometry revealed speech recognition ability of 80 percent in the right ear and of 76 percent in the left ear.  The diagnoses included bilateral hearing loss.

On VA outpatient treatment in May 2010, the Veteran reported "difficulty hearing in church and communicating with his wife" due to bilateral hearing loss.  Otoscopic examination was unremarkable bilaterally.  Audiometric testing showed moderate to moderately severe sensorineural hearing loss from 250-8000 Hertz with "good" speech recognition scores.  Immitance screening showed "essentially normal middle-ear mobility and pressure bilaterally."  The VA clinician stated that the Veteran's "sensorineural hearing loss can be expected to continue to result in significant communication problems, especially in noisy listening environments."

In a July 2012 statement, the Veteran's wife stated that the Veteran's hearing problems had worsened significantly during their 12 years of marriage.  "I have a high-pitched voice and need to change to a lower tone and shout for him to hear me.  There are times when he answers the phone and cannot decipher the caller and hangs up on important calls."

On VA hearing loss and tinnitus DBQ in September 2012, the Veteran complained that he had "difficulty understanding conversations especially in the presence of background noise."  The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records.  the Veteran's pure tone thresholds, in decibels, were as follows:




HERTZ



500
1000
2000
3000
4000
RIGHT
50
50
45
70
75
LEFT
50
50
55
70
75

Speech audiometry revealed speech recognition ability of 84 percent in the right ear and of 80 percent in the left ear.  The VA examiner stated that these results were valid for rating purposes and the use of speech discrimination scores was appropriate for the Veteran.  Tympanometry was normal bilaterally.  The diagnosis was bilateral sensorineural hearing loss

Analysis

The Board finds that the preponderance of the evidence is against the Veteran's claim for an initial rating greater than 10 percent for bilateral hearing loss.  The Veteran contends that this disability has worsened significantly, entitling him to a higher initial rating.  The record evidence does not support his assertions concerning the alleged worsening of his service-connected bilateral hearing loss, however.  The Board notes again that the assignment of disability ratings for hearing impairment is derived by a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered.  See Lendenmann, 3 Vet. App. at 349.  Based on the VA examination results in September 2009, the Veteran's right ear hearing loss was assigned a Roman numeral designation of IV and his left ear hearing loss was assigned a Roman numeral designation of IV, which equates to a 10 percent rating for bilateral hearing loss under Table VI.  See 38 C.F.R. § 4.85, Tables VI, VII.  Further, based on VA examination results in September 2012, the Veteran's right ear hearing loss was assigned a Roman numeral designation of III and his left ear hearing loss was assigned a Roman numeral designation of IV, which equates to a 10 percent rating for bilateral hearing loss under Table VI.  See 38 C.F.R. § 4.85, Tables VI, VII.  Neither of the examiners who saw the Veteran in September 2009 and in September 2012 certified that use of speech discrimination test was not appropriate.  There also is no indication either in September 2009 or in September 2012 of an exceptional pattern of hearing impairment such that 38 C.F.R. § 4.86 is applicable.  See 38 C.F.R. § 4.86.  The Veteran also has not identified or submitted any evidence demonstrating his entitlement to an initial rating greater than 10 percent for service-connected bilateral hearing loss.  In summary, the Board finds that the criteria for an initial rating greater than 10 percent for service-connected bilateral hearing loss have not been met.

Extraschedular

The Board must consider whether the Veteran is entitled to consideration for referral for the assignment of an extraschedular rating for his service-connected bilateral hearing loss.  38 C.F.R. § 3.321; Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the Veteran or reasonably raised by the record).

An extraschedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996).  An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). 

If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization.  Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116.

The Board finds that schedular evaluation assigned for the Veteran's service-connected bilateral hearing loss is not inadequate in this case.  Additionally, the diagnostic criteria adequately describe the severity and symptomatology of this disability.  This is especially true because, as noted elsewhere, the assignment of disability ratings for hearing impairment is derived by a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered.  See Lendenmann, 3 Vet. App. at 349.  Moreover, the evidence does not demonstrate other related factors such as marked interference with employment and frequent hospitalization.  It appears that the Veteran has been retired throughout the pendency of this appeal.  He also reported at his September 2009 VA audiology examination that he was not working "although he would like to obtain a job."  He did not indicate, and the record evidence does not show, that he was hospitalized for his service-connected bilateral hearing loss at any time during the pendency of this appeal.  In light of the above, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met.  See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995).

Service Connection Claims

The Veteran contends that he incurred arthritis of the hands, arthritis of the knees, skin cancer at multiple sites on his body, hypertension, and a blood circulation disorder during active service.  He alternatively contends that in-service cold exposure while assigned to Pease Air Force Base in New Hampshire caused or contributed to each of these claimed disabilities.

Law and Regulations

Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service.  38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a).  Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).  Certain chronic diseases, including arthritis and cardiovascular disease (to include hypertension), are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service.  38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a).  

Establishing service connection generally requires (1) medical evidence of a presently existing 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.  Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)); Hickson v. West, 12 Vet. App. 247, 253 (1999).

If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing the second and/or third element of a service connection claim.  See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997).  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.  Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent.  If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology.  See Savage, 10 Vet. App. at 495-498.

In Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), the Federal Circuit recently overruled Savage and limited the applicability of the theory of continuity of symptomatology in service connection claims to those disabilities explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a).  See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); see also 38 C.F.R. § 3.309(a).  Because skin cancer and a blood circulation disorder are not explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a), the Board finds that Savage and the theory of continuity of symptomatology in service connection claims is inapplicable to these claims.  By contrast, because arthritis and hypertension are both considered "chronic" disabilities under 38 C.F.R. § 3.309(a), the theory of continuity of symptomatology remains valid in adjudicating these claims.

It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case.  When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant.  Reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim.  It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility.  See 38 C.F.R. § 3.102.

Factual Background

The Veteran's service treatment records show that, at his enlistment physical examination in February 1955, he denied all relevant pre-service medical history.  Clinical evaluation was completely normal.  The Veteran's blood pressure was 120/70 (or within normal limits).  A chest x-ray was negative.

On periodic physical examination in April 1958, the Veteran again denied all relevant medical history.  Clinical evaluation of his upper and lower extremities and skin was normal.  A Grade II apical systolic soft murmur "with radiation which changes with position, being more noticeable on standing and disappearing on lying in the left lateral position" was noted although the in-service examiner "consider[ed] this a functional murmur."  A chest x-ray was negative.  The Veteran's blood pressure was 118/70 (or within normal limits).  

At his discharge (or separation) physical examination in December 1958, clinical evaluation of the Veteran's upper and lower extremities, skin, and heart was normal.  A chest x-ray was negative.  The Veteran's blood pressure was 120/70.

The post-service evidence shows that, when the Veteran established care with VA on outpatient treatment in January 2001, a history of hypertension "with systolics in the 140s" was noted.  The Veteran denied any "toxic exposures in the military."  The Veteran reported being told "he had some elevated blood pressure."  He still was working.  He denied any hospitalizations or chronic illness.  Physical examination showed blood pressure of 185/98 and pupils equal, round, and reactive to light and accommodation.  The assessment included a possible history of hypertension "which has been present for at least eight months."  The Veteran denied any medical treatment for his hypertension.

On VA outpatient treatment in April 2001, the Veteran complained of 1 wart on his left palm "that comes and goes in cycles," a lesion on the left eye margin, a bump on the left third digit "that is changing the shape of his nail," and a lesion on the right back "that his wife is concerned with."  Objective examination showed a 1 centimeter (cm) nodule distal to the dorsal interphalangeal (DIP) joint on the left third finger with nail dystrophy, a 1 cm waxy brown inflamed plaque with scale on the right back, a 6 millimeter (mm) follicular cyst on the left inner canthus, and a 1 cm "plaque of thickened stratum corneum with maintenance of skin lines on left palm."  The assessment was probable inflamed sebaceous keratosis on the right back which was treated with liquid nitrogen, mucinous cyst on the left third digit, a callous on the left palm, and a small follicular cyst/comedone on the left inner canthus.

On February 6, 2002, the Veteran's complaints included periodic paresthesias in his lower extremity which were in a stocking glove distribution "up to about the mid thigh."  He denied any weakness, objective numbness, positional components, joint or muscle pain, or stiffness.  A history of hypertension with systolic pressure "in the 140s" and seborrheic keratosis was noted.  Physical examination showed blood pressure was 149/88, pupils equal, round, and reactive to light and accommodation, intact extraocular movements, warm extremities without edema, normal motor skills of the bilateral lower extremities, 5/5 muscle strength in the proximal and distal muscle groups, and intact sensation bilaterally.  The assessment included paresthesias with "no evidence of neuropathy on physical examination" and hypertension. 

In April 2002, the Veteran complained of a "thickened area on [the] left palm."  He had treated this area with salicylic acid plasters "intermittently - no real improvement.  He frequently rubs at the lesion."  Objective examination showed a yellow hyperkeratotic plaque on the left fourth metacarpal head.  The assessment was a callus.

In March 2004, the Veteran's complaints included an "itchy mole on back."  His blood pressure was 150/80.  Physical examination showed 1 cm scale lesions on the arms, back, and palm of the hand and a 5 mm raised mole on the back with surrounding excoriations.  The assessment included paresthesias which were stable, eczema, and a mole.

In September 2004, the Veteran complained of a back lesion.  There were "3 lesions grouped together on [right] lower back at previous site" of a seborrheic keratosis that was treated with liquid nitrogen.  The Veteran denied any itching or burning or any history of skin cancer.  He reported that his wife had noticed "the red spots on lower back several months ago."  Objective examination showed 3 erythematous, slightly scaling 4 mm macules "grouped around a central hypopigmented scar" on the right lower back, and no other "worrisome lesions" on the scalp, face, back, trunk, or extremities.  The assessment was 3 erythematous lesions with a question of whether they were basal cell carcinomas.

In October 2005, the Veteran complained of a left hand hyperkeratotic lesion "which was previously frozen" but was not helped by this treatment.  There were no other "worrisome lesions."  A history of multiple squamous cell carcinomas was noted.  Objective examination showed well-healed scars on the lower back, a 3 mm erythematous papule on the left lower outer edge of the lip "not involving the vermillion border," a hyperkeratotic 6 mm skin-colored plaque that was firm and keratotic on the left hand, and "no concerning lesions" on the head, bilateral upper extremities, back, or chest.  The assessment was a history of squamous cell carcinoma of the right back, basal cell carcinoma of the mid-back, and squamous cell carcinoma X2 of the left back with no evidence of recurrence, a hyperkeratotic papule on the left palm which was treated with liquid nitrogen, and a questionable actinic keratosis on the lower left lip which was treated with liquid nitrogen.

On April 17, 2006, the Veteran's complaints included "very itchy skin on legs" and some "white spots on legs.  The Veteran's history included multiple skin cancers on the lower and mid-back and an "itchy 'wart'" on the left palm which waxed and waned.  Objective examination showed skin type II-III, moderate "photodamage," well-healed ovoid scars on the back, a 1 centimeter (cm) thickened skin-colored plaque on the left palm with no visible hemorrhagic punctae, scattered waxy papules on the forearms, scattered xerotic whitish papules on the legs, general xerosis on the lower back and legs, no erythema, and clear face, scalp, and ears.  The assessment was verruca versus callus on the left palm, stucco keratoses on the legs, seborrheic keratoses of the arms, and a history of non-melanoma skin cancers with no recurrence.

On April 26, 2006, no relevant complaints were noted.  Physical examination showed blood pressure of 148/88 and repeat blood pressure of 150/88 with a noted that the Veteran "did not take his [blood pressure] med[ication] today."  The impressions included hypertension.

In December 2006, no complaints were noted.  The Veteran "has not noticed any lesions that concern him."  Objective examination showed 1 3 mm rough papule on the top of the right shoulder and "no other worrisome lesions."  The assessment was actinic keratosis of the right shoulder, which was treated with liquid nitrogen, and a history of non-melanoma skin cancers with no evidence of recurrence.

In September 2007, the Veteran complained of dizziness "with head movement (usually neck extension) or laying down" which had been present "for years" and was "getting worse over the last few months."  The Veteran reported that he sometimes felt lightheaded and "sometimes like the room is spinning 'like when I have a hangover,' and sometimes just feels 'unsteady' when walking."  He denied any dizziness "when standing up."  These episodes of dizziness "last only a few seconds."  His dizziness was accompanied occasionally by nausea but no vomiting.  A history of leg paresthesia and squamous cell carcinoma was noted.  Objective examination showed intact extraocular movements with no nystagmus and normal neurological testing.  The assessment was dizziness of unclear etiology "but history sounds more consistent with vertigo than lightheadedness/presyncope" and most likely benign paroxysmal positional vertigo "given provocation of symptoms by head movement and brief duration."

In December 2007, a history of non-melanoma skin cancers in the lower and mid- back was noted.  There were "no worrisome lesions today."  Objective examination showed scattered rough ill-defined papules "felt more than seen on top of scalp."  The assessment was actinic keratoses.

In a February 2009 statement, the Veteran contended that all of his claimed disabilities "are a result of exposure to extreme cold temperatures while stationed [at] Pease Air Force Base in the state [of] New Hampshire."

On VA outpatient treatment in April 2009, the Veteran complained of a scaly red lesion on the left temple which had been present for several weeks.  A history of squamous cell carcinoma of the right lower back, basal cell carcinoma of the mid-back, and 2 squamous cell carcinomas of the lower back was noted.  Objective examination showed a "rough" ill-defined 4 mm papule on the right forearm and an approximately 7 mm scaly, erythematous, pearly papule on the left temple and "no other worrisome lesions."  The assessment was neoplasm, probable basal cell carcinoma of the left temple which was curetted and desiccated, and an actinic keratosis of the right forearm which was treated with liquid nitrogen.

In May 2010, the Veteran complained of "itching on lower back" but had no other skin concerns.  A history of squamous cell carcinoma of the right lower back, left back, and left temple, and basal cell carcinoma of the mid-back was noted.  Objective examination showed a well-healed scars of the left temple, mid-back, and lower back, a faint 2-3 cm erythematous xerotic patch on the lower back with "no well-demarcated border," and no other "worrisome lesions" on the scalp, face, back, trunk, or bilateral upper extremities.  The assessment included squamous cell carcinoma of the left temple with no evidence of recurrence, non-melanoma skin cancers of the back with no evidence of recurrence, and irritant dermatitis of the lower back.

In July 2010, the Veteran's complaints included hypertension and numbness/tingling "in distal toes."  Objective examination showed blood pressure of 156/80, no edema in the extremities, and good distal pulses.  The assessment included hypertension which was "poorly controlled," and leg paresthesias.

In January 2011, no relevant complaints were noted.  The Veteran's blood pressure was 133/74.  The assessment included hypertension with a note that the Veteran's blood pressure was "at goal."

In June 2011, the Veteran complained of "a tender bump on his right posterior neck" which had existed for more than 6 months.  "He has not noticed any other worrisome lesions."  The Veteran's dermatology history was noted.  Objective examination showed a dark tan on the arms and neck, "extensive sun damage on neck, arms, and upper back," one irregular hyperkeratotic 5 mm papule on the left forearm, a pink "pearly" papule on the right side of the posterior neck, 1 irregularly shaped and colored tan/dark brown macule on the mid back that was 5 mm x 3 mm, and no other worrisome lesions.  The assessment was actinic keratosis on the left forearm which was treated with liquid nitrogen and neoplasms "of uncertain behavior" on the right posterior neck (rule-out basal cell carcinoma) and mid-back (rule-out malignant melanoma versus junctional nevus).

In September 2011, the Veteran's complaints included pain in his distal fingers "but this is chronic and relatively unchanged."  The Veteran's blood pressure was 138/83.  The assessment included hypertension.

The Veteran testified at his July 2012 Travel Board hearing that he had been exposed to cold weather conditions while stationed at Pease Air Force Based in New Hampshire.  See Board hearing transcript dated July 19, 2012, at pp. 2.  The Veteran also asserted that his in-service cold exposure caused his skin cancer at multiple sites on his body.  Id., at pp. 4.  He testified that his hands and feet were numb at night when he tried going to sleep.  Id., at pp. 6.  

In a July 2012 statement submitted at the Travel Board hearing along with a waiver of RO consideration, the Veteran's wife contended that the Veteran "has a problem with being cold most of the time."  The Veteran also was unable to use his hands because "he has a problem holding on to anything."  He had "severe pain in his hands and knees due to stiffness."

On VA artery and vein conditions DBQ in September 2012, the Veteran's complaints included a circulation disorder "because hands and feet will feel cold."  The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records.  This examiner stated that there was no history of any circulation diagnosis, clotting disorder, or deep vein thrombosis.  The Veteran also did not have any distal hair loss, no thin, shiny skin, no nail disorders, and no fungal infections.  He further did not experience Raynaud's syndrome.  An ultrasound of the aorta was normal.  An ankle/brachial index testing was performed and was uncompressible at 200.  The VA examiner opined that the Veteran's claimed blood circulation disorder was less likely than not related to active service.  The rationale for this opinion was that the Veteran "does not have a circulation disorder."  The examiner stated that the Veteran's un-compressible ankle/brachial index "is a reflection of his poorly controlled hypertension" and there was no x-ray evidence of any hardening of the arteries in the foot/ankle.  Accordingly, the VA examiner opined that there was no relationship between the Veteran's claimed blood circulation disorder and any alleged in-service cold exposure.  This examiner also opined that there was "no documentation that any cold injury has ever occurred.  NO evidence of frost bite.  NO records supporting any disorders from 1958 to 1999."  This examiner stated further that the Veteran "does not have the conditions that are recognized as having been caused by cold injury."  The examiner's opinion also was based on a review of the claims file and relevant medical literature.  No diagnosis was rendered.

On VA scars/disfigurement DBQ in September 2012, no relevant complaints were noted.  The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records.  A history of squamous cell carcinoma shave excisions of the left temple and right posterior trunk was noted.  Physical examination showed no painful or unstable scars of the trunk or extremities, no burn scars, a superficial non-linear scar measuring 1.5 x 1.0 cm on the posterior trunk, no painful or unstable scars of the head, face, or neck, and a 1.0 x 0.9 cm scar on the left temple with hypo- and hyperpigmentation.  The VA examiner opined that the Veteran's skin disability was less likely than not related to active service.  He found instead that the Veteran's skin conditions were "solely due to extended sun exposure and a normal finding for any person of this Veteran's age.  None of these skin conditions are related in any way to cold exposure.  Especially as no frost bite to create frost bite scars in which the skin cancer has been documented."  This examiner stated that there was "no documentation that any cold injury has ever occurred.  NO evidence of frost bite.  NO records supporting any disorders from 1958 to 1999."  This examiner stated further that the Veteran "does not have the conditions that are recognized as having been caused by cold injury."  The opinion also was based on a review of the claims file and relevant medical literature.  The diagnoses were left temple scar, status-post squamous cell carcinoma excision, and a scar on the posterior trunk.

On VA knee and lower leg DBQ in September 2012, the Veteran's complaints included gradual onset bilateral knee pain with squatting and on stairs.  The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records.  The Veteran denied having any knee surgery or injury, effusions, or inflammatory arthritis.  He denied that any flare-ups impacted knee function.  Range of motion testing of the knees showed flexion to 130 degrees with no objective evidence of painful motion bilaterally and extension to zero degrees with no objective evidence of painful motion bilaterally.  The Veteran was able to perform repetitive range of motion testing with no additional  limitation of motion bilaterally.  There was no functional loss or functional impairment of the knee and lower leg.  Physical examination of the knees showed no tenderness to palpation, 5/5 strength, no joint instability, no evidence or history of recurrent patellar subluxation/dislocation, and no evidence of shin splints.  The Veteran did not use any assistive devices for ambulation.  X-rays showed degenerative or traumatic arthritis in both knees, "borderline" narrowing of the left knee medial joint compartment, "very minimal spurring of both intercondylar notch regions," and a possible left knee joint effusion.  There was no x-ray evidence of patellar subluxation.  The Veteran's bilateral knee condition affected his squatting and climbing ladders or repeated stairs.  The VA examiner stated, " The level of osteoarthritis changes in the knees is very minimal considering this Veteran's age and work history."  This examiner opined that the Veteran's bilateral knee disability was less likely than not related to active service.  The rationale for this opinion was that the Veteran had minimal bilateral knee degenerative osteoarthritis "from active living and has NO relationship to cold exposure with no cold injury" in service.  The rationale also was that knee arthritis "is not in the documented list of arthritis types from cold injury unless the entire leg has been frozen."  The examiner's opinion also was based on a review of the claims file and relevant medical literature.  The diagnosis was osteoarthritis of both knees.

On VA hand and finger conditions DBQ in September 2012, the Veteran complained of gradual onset of decreased extension of second, third, fourth fingers of both hands "with no tendon nodules or significant Dupuytren's finger deformities."  The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records.  The Veteran was right-hand dominant.  He denied that flare-ups impacted the function of his hand.  Physical examination showed limitation of motion or evidence of painful motion in the right index finger, right long finger, right ring finger, left index finger, left long finger, and left ring finger, no gap between the thumb pad and the fingers, no gap between any fingertips and the proximal transverse crease of the palm or evidence of painful motion in attempting to touch the palm with the fingertips, osteoarthritis of the bony joint in the dorsal interphalangeal (DIP) joints of the bilateral long fingers, ring fingers, and index fingers, no nail deformities, minimal Dupuytren's contracture, 4/5 hand grip bilaterally, and no ankylosis.  Range of motion testing showed an inability to extend the index and long fingers of both hands fully with extension limited to between 0 and 30 degrees of flexion without objective evidence of painful motion.  The VA examiner noted that the Veteran "worked with his hands all his life and in the logging industry, [and in] manufacturing stoves."  This examiner also noted there was no documented in-service cold injury and no history of Raynaud's syndrome.  The Veteran was able to perform repetitive-use testing with 3 repetitions.  There was no additional limitation of motion for any fingers post-testing.  There was functional loss or functional impairment of the fingers or thumb due to less movement than normal in the bilateral long fingers, ring fingers, and index fingers and deformity in the bilateral long fingers, ring fingers, and index fingers.  The Veteran complained of pain proximal to the third finger metacarpophalangeal (MCP) joint "over the tendon only."  X-rays showed degenerative or traumatic arthritis in multiple joints of both hands.  The VA examiner opined that the Veteran's bilateral hand and finger conditions were less likely than not related to active service.  This examiner stated that the Veteran's osteoarthritis and minimal Dupuytren's contracture were "NOT caused by cold injuries but are most likely due to work and genetic predisposition.  There has never been a loss of the tips of the digits."  The examiner's opinion also was based on a review of the claims file and relevant medical literature.  The diagnoses were osteoarthritis of both hands and Dupuytren's contracture of the second, third, and fourth fingers of both hands.

On VA skin diseases DBQ in September 2012, no relevant complaints were noted.  A history since 2000 was noted of skin cancers on the scalp, back, left temple, and lower legs with the squamous cell cancers on the left temple and back "completely excised."  The VA examiner noted that the Veteran "HAS NO SCARS FROM ANY COLD EXPOSURE/INJURY AND THESE ARE THE ONLY PLACES THAT SKIN CANCERS HAVE BEEN DOCUMENTED AS RELATED TO A COLD INJURY."  (Emphasis in original.)  The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records.  The Veteran's skin conditions did not cause scarring or disfigurement of the head, face, or neck.  He also had no systemic manifestations associated with his skin conditions.  Although the Veteran had experienced a malignant neoplasm, his treatment with surgery had been completed and he was "in watchful waiting status."  It also was noted that an actinic keratosis on the scalp had been treated with liquid nitrogen in December 2007.  Physical examination showed no skin lesions present "at this time."  The VA examiner opined that the Veteran's skin disability was less likely than not related to active service.  He found instead that the Veteran's skin conditions were "solely due to extended sun exposure and a normal finding for any person of this Veteran's age.  None of these skin conditions are related in any way to cold exposure.  Especially as no frost bite to create frost bite scars in which the skin cancer has been documented."  The examiner's opinion also was based on a review of the claims file and relevant medical literature.  The diagnoses were squamous cell cancer diagnosed in May 2004 and in March 2009, actinic keratosis diagnosed in 2004, and stucco keratosis diagnosed in September 2006.

On VA hypertension DBQ in September 2012, the Veteran complained of hypertension since 1999 when it had been diagnosed and he had been given medication to treat it.  The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records.  A history of diastolic blood pressure elevation of predominantly 100 or more was noted.  A chest x-ray was stable.  The Veteran's blood pressure was 199/98, 181/87, and 175/93.  The VA examiner opined that the Veteran's hypertension was less likely than not related to active service.  He found instead that the Veteran's hypertension "was not diagnosed until 1999 and [there was] no documentation of any continuity of care" between his separation from service and 1999 when he was diagnosed as hypertension.  The rationale for this opinion was that there was "no documentation" in the medical literature that hypertension is caused by cold exposure "or even a cold injury such as frost bite."  The examiner stated further that the etiology for the Veteran's hypertension "would be essential hypertension with no bodily injury as causation."  The VA examiner also stated that the Veteran's hypertension was not related to his diabetes mellitus "as it was present for many years prior to onset of diabetes and has not been aggravated by the diabetes."  The examiner's opinion also was based on a review of the claims file and relevant medical literature.  The diagnosis was hypertension.

On VA cold injury residuals DBQ in September 2012, no relevant complaints were noted.  The Veteran reported serving at Pease Air Force Based during active service when he was exposed to extreme cold.  The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records.  This examiner stated:

This Veteran has not had a cold injury identified by frostbite in service.  Therefore, he could only be classified as having non-freezing cold exposure.  He has never had trench foot, immersion foot, paddy foot.  These are the recognized non-freezing cold exposure conditions.  He has never had and no documentation of: chronic fungal infection of the feet, no dystrophic toe nails, no hyperhidrosis of the feet, no abnormal skin color or thinning foot skin, has never had Raynaud's, no foot joint pain/stiffness, no weakness of the feet or hands, no fallen foot arches, no swelling/edema of feet, no ulceration of feet and no cold injury scars anywhere, no shiny atrophied or deteriorated foot skin, no loss of foot hair.  He does have an abnormal sensation to the soles of the feet and some...pain in the soles.  However, this Veteran has had the criteria for diabetes type 2 since 2003 with no treatment and these two symptoms are best explained by diabetic neuropathy and not a cold exposure or injury.

The Veteran was right-hand dominant.  He reported experiencing arthralgia or other pain in the hands and feet.  X-rays of the hands and feet all showed osteoarthritis.  No diagnosis was rendered.  The VA examiner opined that there was "no documentation that any cold injury has ever occurred.  NO evidence of frost bite.  NO records supporting any disorders from 1958 to 1999."  This examiner stated further that the Veteran "does not have the conditions that are recognized as having been caused by cold injury."  The only finding of peripheral neuropathy of the soles of the feet is more than "90% explained by diabetes type 2."  The examiner's opinion also was based on a review of the claims file and relevant medical literature.  

Analysis

The Board finds that the preponderance of the evidence is against the Veteran's claims of service connection for arthritis of both hands, arthritis of both knees, skin cancer at multiple sites on the body, hypertension, and for a blood circulation disorder, each to include as due to cold exposure.  The Veteran has asserted that he incurred each of these claimed disabilities as a result of in-service exposure to cold weather while stationed at Pease Air Force Base.  The record evidence does not support the Veteran's assertions concerning in-service incurrence of any of these claimed disabilities, to include as due to cold exposure, however.  The Veteran's service treatment records indicate that he was stationed at Pease Air Force Base.  These records show no complaints of or treatment for any of the Veteran's claimed disabilities, although the Board acknowledges that the absence of service treatment records does not preclude granting service connection for a claimed disability.  See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms").

The post-service evidence shows that, although the Veteran experiences currently disability due to arthritis in the hands and knees and hypertension, these disabilities are not related to active service or any incident of service, to include as due to cold exposure.  The Board notes initially that, although the Veteran has asserted that he experiences disability due to skin cancer at multiple sites on the body and a blood circulation disorder which could be attributed to active service, to include as due to cold exposure, the record evidence does not support his assertions.  It shows instead that the Veteran does not experience any current disability due to skin cancer at multiple sites on the body or a blood circulation disorder.  The Board acknowledges in this regard that the Veteran has complained of and been treated for skin cancer at multiple sites on the body since his service separation in 1958.  It appears, however, that the Veteran's skin cancers were resolved with post-service treatment, including surgical excision, and do not result in any current disability (as seen on VA skin diseases DBQ in September 2012).  Physical examination of the Veteran in September 2012 showed no skin lesions present "at this time."  The VA examiner opined that the Veteran's skin disability was less likely than not related to active service.  He found instead that the Veteran's skin conditions were "solely due to extended sun exposure and a normal finding for any person of this Veteran's age.  None of these skin conditions are related in any way to cold exposure.  Especially as no frost bite to create frost bite scars in which the skin cancer has been documented."  The diagnoses were squamous cell cancer diagnosed in May 2004 and in March 2009, actinic keratosis diagnosed in 2004, and stucco keratosis diagnosed in September 2006.

Although the Veteran also has complained of a blood circulation disorder, to include as due to cold exposure, since service, there was no objective evidence of any blood circulation disorder which could be attributed to active service at his VA artery and vein conditions DBQ in September 2012.  At that time, the VA examiner opined that the Veteran's claimed blood circulation disorder was less likely than not related to active service.  The rationale for this opinion was that the Veteran "does not have a circulation disorder."  The examiner stated that the Veteran's un-compressible ankle/brachial index "is a reflection of his poorly controlled hypertension" and there was no x-ray evidence of any hardening of the arteries in the foot/ankle.  Accordingly, the VA examiner opined that there was no relationship between the Veteran's claimed blood circulation disorder and any alleged in-service cold exposure.  This examiner also noted that there was "no documentation that any cold injury has ever occurred.  NO evidence of frost bite.  NO records supporting any disorders from 1958 to 1999."  No diagnosis was rendered.

A service connection claim must be accompanied by evidence which establishes that the claimant currently has a disability.  Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).  Service connection is not warranted in the absence of proof of current disability.  The Board has considered whether the Veteran experienced skin cancer at multiple sites on the body or a blood circulation disorder at any time during the pendency of this appeal.  Service connection may be granted if there is a disability at some point during the claim even if it later resolves or becomes asymptomatic.  McClain v. Nicholson, 21 Vet. App. 319 (2007).  In this case, although there is evidence that the Veteran experienced skin cancer at multiple sites on the body since service separation, the evidence does not support a finding that this disability is related to active service or any incident of service, to include as due to cold exposure.  There also is no evidence of a blood circulation disorder at any time during the pendency of this appeal.  Absent evidence of current disability which could be attributed to active service, the Board finds that service connection for skin cancer at multiple sites on the body and for a blood circulation disorder is not warranted.

With respect to the Veteran's service connection claims for arthritis of both hands, arthritis of both knees, and hypertension, each to include as due to cold exposure, the Board recognizes that he experiences current disability due to arthritis in his hands and knees and hypertension (as discussed above).  The record evidence does not support the Veteran's assertions regarding continuity of symptomatology since service or an etiological relationship between any current arthritis or hypertension and active service, to include as due to cold exposure.  As noted elsewhere, because arthritis and hypertension are both considered "chronic" disabilities under 38 C.F.R. § 3.309(a), the theory of continuity of symptomatology remains valid in adjudicating these claims.  See Walker, 708 F.3d at 1331; see also 38 C.F.R. § 3.309(a).  As also noted elsewhere, the lack of contemporaneous records containing a diagnosis of arthritis or hypertension does not preclude granting service connection.  See Buchanan, 451 F.3d at 1337, and Barr, 21 Vet. App. at 303.  The record evidence shows that the Veteran's hypertension was not diagnosed until 1999, more than 40 years after his service separation in 1958.  And it appears that the Veteran was not diagnosed as having arthritis in his hands and knees until he was examined most recently in September 2012.  The Board notes that evidence of a prolonged period without medical complaint, and the amount of time that elapsed since military service, can be considered as evidence against the claim.  Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). 

Following VA knee and lower leg conditions DBQ in September 2012, the VA examiner stated, " The level of osteoarthritis changes in the knees is very minimal considering this Veteran's age and work history."  This examiner opined that the Veteran's bilateral knee disability was less likely than not related to active service.  The rationale for this opinion was that the Veteran had minimal bilateral knee degenerative osteoarthritis "from active living and has NO relationship to cold exposure with no cold injury" in service.  The rationale also was that knee arthritis "is not in the documented list of arthritis types from cold injury unless the entire leg has been frozen."  The Veteran does not contend, and the evidence does not show that either of his legs were frozen when he allegedly was exposed to cold while stationed at Pease Air Force Base during active service.

Similarly, following VA hand and finger conditions DBQ in September 2012, the VA examiner noted that the Veteran "worked with his hands all his life and in the logging industry, [and in] manufacturing stoves."  This examiner also noted that there was no documented in-service cold injury and no history of Raynaud's syndrome.  This VA examiner opined that the Veteran's bilateral hand and finger conditions (which he diagnosed as osteoarthritis of both hands and Dupuytren's contracture of the second, third, and fourth fingers of both hands) were less likely than not related to active service.  This examiner stated that the Veteran's osteoarthritis and minimal Dupuytren's contracture were "NOT caused by cold injuries but are most likely due to work and genetic predisposition.  There has never been a loss of the tips of the digits."  

The Veteran submitted an article about cold injuries from the Internet in support of his claims.  A medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion.  Mattern v. West, 12 Vet. App. 222, 228 (1999).; see also Sacks v. West, 11 Vet. App. 314 (1998).  The medical article submitted by the Veteran in this case was not accompanied by the opinion of any medical expert linking any of his claimed disabilities to active service, including as due to cold exposure. Thus, the medical article submitted by the Veteran is insufficient to establish the medical nexus opinion required for causation.  See Sacks, 11 Vet. App. at 317 (citing Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996)); see also Libertine v. Brown, 9 Vet. App. 521, 523 (1996).

In summary, there is no competent opinion of record contrary to the negative nexus opinions provided by the VA examiners in September 2012 concerning the contended causal relationship between the Veteran's current arthritis of the hands, arthritis of the knees, and hypertension and active service, to include as due to cold exposure.  Additionally, following VA cold injury residuals DBQ in September 2012, the VA examiner stated, "This Veteran has not had a cold injury identified by frostbite in service."  This VA examiner also opined that there was "no documentation that any cold injury has ever occurred.  NO evidence of frost bite.  NO records supporting any disorders from 1958 to 1999."  This examiner stated further that the Veteran "does not have the conditions that are recognized as having been caused by cold injury."  The only finding of peripheral neuropathy of the soles of the feet is more than "90% explained by diabetes type 2."  The Veteran also has not identified or submitted any evidence, to include a medical nexus, which relates any of his claimed disabilities to active service, to include as due to cold exposure.  Thus, the Board finds that service connection for arthritis of both hands, arthritis of both knees, and hypertension, each to include as due to cold exposure, also is not warranted.

The Board finally finds that service connection for arthritis of both hands, arthritis of both knees, and for hypertension is not warranted on a presumptive basis.  See 38 C.F.R. §§ 3.307, 3.309.  The record evidence does not show, and the Veteran does not contend, that he experienced any of these chronic disabilities within the first post-service year (i.e., by December 1959) such that service connection is warranted on a presumptive basis as a chronic disease.  Id.

In this decision, the Board has considered all lay and medical evidence as it pertains to the issue.  38 U.S.C.A. § 7104(a) ("decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) (VA "shall consider all information and lay and medical evidence of record in a case"); 38 C.F.R. § 3.303(a) (service connection claims "must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence").  In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990).  

Competency of evidence differs from weight and credibility.  Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted.  Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown,6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify").  A Veteran is competent to report symptoms that he experiences at any time because this requires only personal knowledge as it comes to him through his senses.  Layno, 6 Vet. App. at 470; Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (holding that, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation).  Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, arthritis, skin cancer, hypertension, and a blood circulation disorder fall outside the realm of common knowledge of a lay person.  See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer).

The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence.  See Buchanan, 451 F.3d at 1337, and Barr, 21 Vet. App. at 303.  In determining whether statements submitted by a Veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment.  Caluza v. Brown, 7 Vet. App. 498 (1995).  

As part of the current VA disability compensation claims, in recent statements and sworn testimony, the Veteran has asserted that his symptoms of arthritis, skin cancer, hypertension, and a blood circulation disorder have been continuous since service.  He asserts that he continued to experience symptoms relating to arthritis (pain in his hands and knees), skin cancer, hypertension, and a blood circulation disorder after he was discharged from the service.  In this case, after a review of all the lay and medical evidence, the Board finds that the weight of the evidence demonstrates that the Veteran did not experience continuous symptoms of any of these disabilities after service separation.  Further, the Board concludes that his assertion of continued symptomatology since active service, while competent, is not credible.  

The Board finds that the Veteran's more recently-reported history of continued symptoms of arthritis, skin cancer, hypertension, and a blood circulation disorder since active service is inconsistent with the other lay and medical evidence of record.  Indeed, while he now asserts that all of these disorders began in service, in the more contemporaneous medical history he gave at the service separation examination, he denied any relevant history or complaints of symptoms.  Specifically, the service separation examination report reflects that the Veteran was examined and he was found to be normal clinically.  His in-service history of symptoms at the time of service separation is more contemporaneous to service so it is of more probative value than the more recent assertions made many years after service separation.  See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the Veteran wrote during treatment than to his subsequent assertion years later).  

The post-service medical evidence does not reflect complaints or treatment related to arthritis, skin cancer, and hypertension for several decades following active service.  The Board emphasizes the multi-year gap between discharge from active service (1958) and initial reported symptoms related to hypertension in approximately 2001 (a 43-year gap), arthritis in approximately 2002 (a 44-year gap), and skin cancer in approximately 2005 (a 47-year gap).  See Maxson, 230 F.3d at 1333; see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board's denial of service connection where Veteran failed to account for lengthy time period between service and initial symptoms of disability).  As noted elsewhere, the post-service evidence shows no complaints or treatment related to a blood circulation disorder at any time since the Veteran's service separation.

When the Veteran sought to establish medical care with VA after service in January 2001, he reported only a history of hypertension.  Such histories reported by the Veteran for treatment purposes are of more probative value than the more recent assertions and histories given for VA disability compensation purposes.  Rucker, 10 Vet. App. at 67 (holding that lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care).

He did not claim that symptoms of his disorders began in (or soon after) service until he filed his current VA disability compensation claims.  Such statements made for VA disability compensation purposes are of lesser probative value than his previous more contemporaneous in-service histories and his previous statements made for treatment purposes.  See Pond v. West, 12 Vet. App. 341 (1999) (finding that, although Board must take into consideration the Veteran's statements, it may consider whether self-interest may be a factor in making such statements). 

These inconsistencies in the record weigh against the Veteran's credibility as to the assertion of continuity of symptomatology since service.  See Madden, 125 F.3d at 1481 (finding Board entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Caluza v. Brown, 7 Vet. App. 498, 512 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (upholding Board's finding that a Veteran was not credible because lay evidence about a wound in service was internally inconsistent with other lay statements that he had not received any wounds in service).  

The Board has weighed the Veteran's statements as to continuity of symptomatology and finds his current recollections and statements made in connection with a claim for VA compensation benefits to be of lesser probative value than his previous more contemporaneous in-service history and findings at service separation, the absence of complaints or treatment for years after service, his previous statements made for treatment purposes, and his own previous histories of onset of symptoms given after service.  For these reasons, the Board finds that the weight of the lay and medical evidence is against a finding of continuity of symptoms since service separation.


ORDER

Entitlement to an initial rating greater than 10 percent for bilateral hearing loss is denied.

Entitlement to service connection for arthritis of both hands, including as due to cold exposure is denied.

Entitlement to service connection for arthritis of both knees, including as due to cold exposure, is denied.

Entitlement to service connection for skin cancer at multiple sites on the body, including as due to cold exposure, is denied.

Entitlement to service connection for hypertension, including as due to cold exposure, is denied.

Entitlement to service connection for a blood circulation disorder, including as due to cold exposure, is denied.


REMAND

The Veteran also contends that he incurred vertigo during active service, to include as due to cold exposure.  

Following VA ear conditions DBQ in October 2012, the VA examiner stated that the Veteran did not have and had never been diagnosed as having an ear or peripheral vestibular condition (such as vertigo).  The VA examiner opined, "Since vertigo symptoms reportedly occurred around the time of service, it is more likely than not that his positional vertigo is more like than not service related."  Unfortunately, because it was not clear from a review of this examination report whether the VA examiner had reviewed the Veteran's claims file before offering this opinion, RO personnel contacted this examiner and asked him to provide an addendum to this report stating whether claims file review had been accomplished.  In the March 2013 addendum to the October 2012 VA ear conditions DBQ, the VA examiner stated that, after reviewing the Veteran's claims file, "I cannot make a conclusion on whether his vertigo is service connected without resorting to mere speculation. While the patient describes vertigo that began in service, his [claims] file is silent for any mention of vertigo or head trauma."

Unfortunately, the VA examiner concluded in March 2013 that it would be "mere speculation" to find a causal relationship between the Veteran's claimed vertigo and active service, including as due to cold exposure.  The Court has held that, when VA undertakes to provide a Veteran with an examination, that examination must be adequate for VA purposes.  See Barr, 21 Vet. App. at 303.  The Court also has held that medical opinions using the "mere speculation" language, without more, generally are disfavored because they are inconclusive as to the origin of a disability.  See Warren v. Brown, 6 Vet. App. 4, 6 (1993); Sklar v. Brown, 5 Vet. App. 104, 145-6 (1993).  The Court has explained that opinions which contain the "mere speculation" language, without more, amount to 'nonevidence' neither for nor against the claim because service connection may not be based on speculation or remote possibility.  See Bloom v. West, 12 Vet. App. 185 (1999) (holding that a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty).  The Court recently held in Jones v. Shinseki, 23 Vet. App. 382 (2010), that, when a medical examiner concludes that he or she is unable to provide a nexus opinion without speculation, this alone does not make the medical opinion inadequate; a medical opinion with such language may be adequate if the examiner sufficiently explains the reasons for this inability.  Id. at 389-90.  See also Obert v. Brown, 5 Vet. App. 30, 33 (1993) (noting that speculative opinion is not legally sufficient to establish service connection).  Before the Board can rely on an examiner's conclusion that an etiology opinion would be speculative, however, the examiner must explain the basis for such an opinion or the basis must otherwise be apparent in the Board's review of the evidence.  Cf. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (finding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions").  Furthermore, VA must ensure that any medical opinion, including one that states no conclusion can be reached without resorting to speculation, is "based on sufficient facts or data."  See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2009). Therefore, it must be clear from either the examiner's statements or the Board's decision that the examiner has considered "all procurable and assembled data" by obtaining all tests and records that might reasonably illuminate the medical analysis.  See Daves v. Nicholson, 21 Vet. App. 46 (2007).  When the record leaves this issue in doubt, it is the Board's duty to remand for further development.  

As noted elsewhere, the lack of contemporaneous service treatment records does not preclude granting service connection for a claimed disability.  See Buchanan, 451 F.3d at 1337; Barr, 21 Vet. App. at 303.  The October 2012 VA examiner who completed the ear conditions DBQ appears to have contradicted his initial opinion finding a causal relationship between the Veteran's claimed vertigo and active service with his subsequent finding in March 2013 it was "mere speculation" to conclude that such an etiological relationship existed because there were no service treatment records documenting the presence of vertigo during service.  This frustrates the Board's review as it is not clear from the record evidence whether the Veteran currently experiences vertigo and, if so, whether it is related to active service, including as due to cold exposure.

Given the foregoing, the Board finds that, because the VA examiner used the "mere speculation" language in his March 2013 addendum to the October 2012 VA ear conditions DBQ regarding the etiology of the Veteran's vertigo and did not provide any further explanation of his opinion, and because this examination report is internally contradictory concerning the etiology of the Veteran's claimed vertigo, it is inadequate for VA purposes.  See also 38 C.F.R. § 4.2.  Thus, on remand, the Veteran should be scheduled for an updated VA examination which addresses the contended etiological relationship between vertigo and active service, including as due to cold exposure, without resorting to mere speculation.

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.  Contact the Veteran and ask him to identify all VA and non-VA clinicians who have treated him for vertigo since his service separation.  Advise the Veteran not to resubmit any records already provided to VA.  Obtain all VA treatment records which have not been obtained already.  Once signed releases are received from the Veteran, obtain all private treatment records which have not been obtained already.  A copy of any records obtained, to include a negative reply, should be included in the claims file.

2.  Schedule the Veteran for appropriate examination to determine the nature and etiology of his vertigo.  If possible, this examination should be scheduled with a different VA clinician than the clinician who examined the Veteran in October 2012.  The claims file and a copy of this remand must be provided to the examiner for review.  All appropriate testing should be conducted.  The Veteran should be asked to provide a complete medical history, if possible.  Based on a review of the claims file and the results of the Veteran's physical examination, and the Veteran's statements regarding the development and treatment of his claimed disorder, the examiner is asked to opine whether it is at least as likely as not (i.e., a 50 percent or greater probability) that vertigo, if diagnosed, is related to active service or any incident of service, including as due to cold exposure.  A complete rationale must be provided for any opinions expressed.  If the requested opinion cannot be provided without resorting to mere speculation, then the examiner must explain why this is so.

The examiner is advised that the Veteran contends that he was exposed to cold while serving at Pease Air Force Base in New Hampshire during active service and such exposure caused or contributed to his current vertigo.  The examiner also is advised that the Veteran's available service treatment records show that he was stationed at Pease Air Force Base in New Hampshire while on active service.  The examiner further is advised that the Veteran's available service treatment records show no complaints of or treatment for vertigo during active service, although this does not preclude granting service connection for vertigo.

3.  The Veteran should be given adequate notice of the requested examination which includes advising him of the consequences of his failure to report to the examination.  If he fails to report to the examination, then this fact should be noted in the claims file and a copy of the scheduling of examination notification or refusal to report notice, whichever is applicable, should be obtained by the RO and associated with the claims file.

4.  Review all evidence received since the last prior adjudication and readjudicate the Veteran's claim.  If the determination remains unfavorable to the Veteran, then the RO should issue a supplemental statement of the case that contains notice of all relevant actions taken, including a summary of the evidence and applicable law and regulations considered pertinent to the issue.  An appropriate period of time should be allowed for response by the Veteran.  Thereafter, the case should be returned to the Board for further appellate consideration, if 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).



______________________________________________
WAYNE M. BRAEUER
Veterans Law Judge, Board of Veterans' Appeals

Department of Veterans Affairs