Citation Nr: 1320742 Decision Date: 06/27/13 Archive Date: 07/05/13 DOCKET NO. 09-41 834 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Sioux Falls, South Dakota THE ISSUES 1. Entitlement to service connection for diabetes mellitus type II claimed as a result of exposure to herbicides. 2. Entitlement to service connection for peripheral neuropathy of the bilateral upper and lower extremities claimed as secondary to diabetes mellitus type II. 3. Entitlement to service connection for heart disease with myocardial infarction claimed as a result of exposure to herbicides or as secondary to diabetes mellitus type II or service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD John Francis, Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from November 1960 to November 1963 and in the U.S. Navy from November 1964 to November 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Sioux Falls, South Dakota. The Board observes that the issues regarding diabetes mellitus type II and heart disease were previously characterized as applications to reopen such claims. VA regulations provide that, at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim, notwithstanding paragraph (a) of the same section (which defines new and material evidence). The regulation further identifies service records related to a claimed in-service event, injury, or disease as relevant service department records. 38 C.F.R. § 3.156(c)(1)(i) (2012). As such, new and material evidence is not needed to reopen a previously denied claim when relevant service treatment records and/or any other relevant service department records are received after a prior final denial. Rather, the claim is simply reviewed on a de novo basis. In the instant case, a record of the Veteran's attendance at Marine Corps administered training course in May 1966, a Defense Personnel Records Image Retrieval System (DPRIS) summary of the operations of USS Walke (DD-723) in 1965 and 1966, and deck logs from USS Walke in August 1965 and September 1965 were associated with the file subsequent to the previous denials of the Veteran's claims. The documents pertaining to the Veteran's in-service training and ship operating history that addressed his location and activities when deployed to the Western Pacific in 1965-66. In the instant case, the central inquiry involves whether the Veteran's duties placed him on the landmass of Vietnam or on a ship that docked on the shores or piers of Vietnam, operated temporarily in the Vietnam inland waterways, or operated on close coastal waters for extended periods so as to presume his exposure to herbicides. The Board finds that the newly received service department records contain details surrounding the Veteran's in-service duties and location during the time he alleges that he was exposed to herbicides. Therefore, the newly received service department records fall within the scope of 38 C.F.R. § 3.156(c) and, as such, the Veteran's claims will be reviewed on a de novo basis. Therefore, the issues have been characterized as shown on the first page of the decision. In his October 2009 substantive appeal, the Veteran requested a hearing before a Veterans Law Judge sitting at the RO. His requested hearing was scheduled for April 2011; however, the Veteran withdrew his request for a hearing in writing in March 2011. 38 C.F.R. § 20.704(d) (2012). The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the Virtual VA claims file does not reveal any additional documents pertinent to the present appeal. The issue of entitlement to service connection for heart disease is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, D.C. FINDINGS OF FACT 1. The Veteran was not present on the landmass of Vietnam and did not serve on a ship that docked on the shores or piers of Vietnam, operated temporarily in the Vietnam inland waterways, or operated on close coastal waters for extended periods and, therefore, is not presumed to have been exposed to herbicides. 2. Diabetes mellitus type II is not shown to be causally or etiologically related to any disease, injury, or incident in service, and did not manifest within one year of the Veteran's discharge from service. 3. Peripheral neuropathy of the bilateral upper and lower extremities is not shown to be causally or etiologically related to any disease, injury, or incident in service, and is not caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. Diabetes mellitus type II was not incurred in or aggravated by the Veteran's active duty military service, nor may it be presumed to have been incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1116, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 2. Peripheral neuropathy of the bilateral upper and lower extremities was not incurred in or aggravated by the Veteran's active duty military service and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), 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 (AOJ) decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a March 2009 letter, sent prior to the initial unfavorable decision issued in May 2009, advised the Veteran of the evidence and information necessary to substantiate his service connection claims as well as his and VA's respective responsibilities in obtaining such evidence and information. In this regard, as relevant to the Veteran's claim for service connection for diabetes mellitus, such letter informed him of the information and evidence necessary to substantiate his claim based on presumptive exposure to herbicides coincident with service in the Republic of Vietnam. Likewise, the letter informed him of the information and evidence necessary to substantiate his claim for service connection for peripheral neuropathy on a secondary basis. Additionally, such letter advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Relevant to the duty to assist, the Veteran's service treatment and personnel records as well as VA and private treatment reports have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. The Veteran has not been afforded a VA examination in connection with his claims for service connection for diabetes mellitus type II and peripheral neuropathy; however, the Board finds that such is not necessary in the instant case. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a Veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the Veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the Veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Court has held that VA is not required to provide a medical examination when there is not credible evidence of an event, injury, or disease in service. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010). Additionally, a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). There is competent evidence of a current disability of diabetes mellitus but no evidence of a relevant injury or disease in service and no credible evidence that the disease may be associated with events in service. In this regard, the Veteran contends only that he is presumed to have been exposed to certain herbicide agents because he performed duty in Vietnam and that the disease is among those presumed to have been caused by that exposure. Factual or presumed exposure to herbicide is not a medical determination. For reasons provided below, the record fails to establish the event causing the contended exposure. Therefore, the criteria for a VA examination have not been met. Moreover, as relevant to the Veteran's claim for service connection for peripheral neuropathy of the bilateral upper and lower extremities, he has only alleged that such disease is secondary to his diabetes mellitus type II. As service connection for diabetes mellitus type II is denied herein, the Veteran lacks legal grounds to establish entitlement to service connection for peripheral neuropathy as secondary to such disease and, therefore, a VA examination is not necessary to decide the claim. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Analysis The Veteran served in the U.S. Army infantryman with service in Germany and as a U.S. Navy seaman with service aboard USS Walke (DD-723), including two deployments to the Western Pacific from March 1965 to September 1965 and from July to October 1966. The deployment operations included periods of time off the coast of the Republic of Vietnam. The Veteran was awarded the Vietnam Service Medal. He contends that he was exposed to certain herbicide agents in Vietnam and that his diabetes mellitus was caused by this exposure. He further alleges that he has peripheral neuropathy of the bilateral upper and lower extremities that was caused or aggravated by his diabetes mellitus. Therefore, he claims that service connection for such disorders is warranted. As an initial matter, the Board observes that the AOJ misunderstood the Veteran's written notes on his October 2009 substantive appeal and construed such statement to indicate that he was claiming, in the alternative, that his diabetes mellitus type II and peripheral neuropathy were secondary to PTSD. In this regard, in a March 2010 statement, the Veteran's representative indicated that the Veteran had reported that his intent was to seek service connection for PTSD and not claim that his diabetes and related conditions were secondary to PTSD. As a result of such misunderstanding, the AOJ erroneous considered such theory of entitlement in subsequent readjudications of the Veteran's case. However, as the Veteran has explicitly indicated that he is not alleging such a theory of entitlement, the Board need not address it further. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as diabetes mellitus, 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. §§ 1101, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For purposes of establishing service connection for a disability resulting from exposure to a herbicide agent, a Veteran who, during active military, naval, or air service, served in the Republic of Vietnam between January 1962 and May 1975, shall be presumed to have been exposed during such service to a herbicide agent, absent affirmative evidence to the contrary demonstrating that a Veteran was not exposed to any such agent during service. 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6). Service connection based on herbicide exposure will be presumed for certain specified diseases that become manifest to a compensable degree within a specified period of time in the case of certain diseases. 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307(a)(6), 3.309(e). Diabetes mellitus is among those diseases for which presumptive service connection is available and must manifest to a degree of 10 percent or more at any time after the last exposure to the specific herbicide agents. 38 U.S.C.A. § 1116(a)(2); 38 C.F.R. § 3.309(e). VA regulations provide that disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Board notes at the outset that the Veteran does not allege, nor does the record reflect, that he first manifested diabetes mellitus during service, or within one year of his discharge from service, or that such is otherwise related to service on a direct basis. In this regard, his service treatment records are silent for any complaints, treatment, or diagnoses referable to diabetes mellitus. Moreover, diabetes mellitus was not diagnosed until at least 1980, as reported by the Veteran, or in 1992, as reflected by the medical records. Specifically, in June 1992, a VA podiatrist noted that the Veteran was under treatment for diabetes and, in September 1994, it was noted that the Veteran had been diagnosed with diabetes and prescribed insulin therapy two years earlier. Rather, the Veteran has claimed that his diabetes mellitus type II is presumptively related to in-service herbicide exposure. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (2008) (claims which have no support in the record need not be considered by the Board as the Board is not obligated to consider "all possible" substantive theories of recovery. Where a fully developed record is presented to the Board with no evidentiary support for a particular theory of recovery, there is no reason for the Board to address or consider such a theory). Specifically, the Veteran alleges that he was exposed to herbicides used in Vietnam while serving aboard the USS Walke. Service personnel records showed that the Veteran served aboard USS Walke (DD 723) from February 1965 to October 1966. The records showed that he was assigned duties as a seaman. In records of treatment by VA mental health clinicians, the Veteran reported that he was a signalman and witnessed his ship conducting shore gunfire support operations along the coast of Vietnam. The DPRIS records of the ship history for deployments to the Western Pacific from March 1965 to September 1965 and again from July 1966 to November 1966. The history confirmed that the ship operated for specified periods of time in areas off the coast of Vietnam, performing operations as a screening vessel for aircraft carriers and for short periods of shore bombardment. Deck logs confirmed that the ship provided gunfire illumination of shore targets. The ship did not enter port or operate in the inshore waters of Vietnam during these deployments. "Service in the Republic of Vietnam," includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii). VA's General Counsel has determined that the regulatory definition (which permits certain personnel not actually stationed within the borders of the Republic of Vietnam to be considered to have served in that Republic) requires that an individual actually have been present within the boundaries of the Republic. See VAOPGCPREC 27-97. Specifically, the General Counsel has concluded that in order to establish qualifying "service in Vietnam" a Veteran must demonstrate actual duty or visitation in the Republic of Vietnam. Service on a deep water naval vessel in waters off the shore of the Republic of Vietnam, without proof of actual duty or visitation in the Republic of Vietnam, does not constitute service in the Republic of Vietnam for purposes of 38 U.S.C.A. § 101(29)(A) (establishing that the term "Vietnam era" means the period beginning on February 28, 1961, and ending on May 7, 1975 in the case of a Veteran who served in the Republic of Vietnam during that period). See VAOPGCPREC 27-97. In Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008), cert. denied, 77 U.S.L.W. 3267 (U.S. Jan. 21, 2009), the Federal Circuit held that VA's interpretation of the phrase "served in the Republic of Vietnam" in 38 U.S.C.A. § 1116, to the effect that a Veteran must set foot on Vietnamese soil, was entitled to deference by the courts. The Board notes that, although prostate cancer and ischemic heart disease are diseases which may be presumed to have resulted from herbicide exposure under the provisions of 38 C.F.R. § 3.309(e), in order to establish a claim of entitlement to service connection for these diseases based on herbicide exposure, there must be evidence that the Veteran served in country in Vietnam for some portion of the applicable time period. VA regulations state that Veterans who served aboard large ocean-going ships that operated in the offshore waters of the Republic of Vietnam are often referred to as "Blue Water" Veterans because of the blue color of the deep offshore waters. They are distinguished from "Brown Water" Veterans who served aboard smaller river patrol and swift boats that operated on the brown-colored rivers, canals, estuaries, and delta areas making up the inland waterways of Vietnam. "Brown Water" Navy and Coast Guard Veterans receive the same presumption of herbicide exposure as Veterans who served on the ground in Vietnam. VA Manual M21-1MR, Part IV, Subpart ii, Chapter 2, Section C, Part 10.k. According to the VA Manual M21-1MR, when a Veteran claims exposure to herbicides during service aboard a Navy or Coast Guard ship that operated on the offshore waters of Vietnam, establish exposure on a presumptive basis if (a) evidence shows the ship docked on the shores or piers of Vietnam, operated temporarily on the Vietnam inland waterways, or operated on close coastal waters for extended periods, with evidence that crew members went ashore, or smaller vessels from the ship went ashore regularly with supplies or personnel; (b) evidence places the Veteran onboard the ship at the time the ship docked to the shore or pier or operated in inland waterways or on close coastal waters for extended periods, (c) and the Veteran has stated that he/she went ashore when the ship docked or operated on close coastal waters for extended periods, if the evidence shows the ship docked to the shore or pier or that crew members were sent ashore when the ship operated on close coastal waters. In the instant case, there is no evidence that the USS Walke docked on the shores or piers of Vietnam, operated temporarily on the Vietnam inland waterways, or operated on close coastal waters for extended periods while the Veteran was aboard. In this regard, the Board observes that a December 2010 document entitled Navy and Coast Guard Ships Associated with Service in Vietnam and Exposure, which is contained in the claims file, the USS Walke is not listed as a ship that operated primarily or exclusively on Vietnam's inland waterways. The Board observes that such document was updated in January 2011 and, after the issuance of the December 2010 supplemental statement of the case, an updated page from such document was associated with the claims file. Such page reflects that the USS Walke operated on the Mekong River Delta at Vung Ganh Rei on September 2, 1969. However, the Veteran served aboard such ship from February 1965 to October 1966 and was discharged in November 1966. Therefore, he could not have been aboard the USS Walke in September 1969. Moreover, while the AOJ did not consider such newly received document, the Board finds that it is essentially duplicative of the evidence of record and thus irrelevant to the claim. In this regard, such document still fails to demonstrate that the USS Walke docked on the shores or piers of Vietnam, operated temporarily on the Vietnam inland waterways, or operated on close coastal waters for extended periods while the Veteran was aboard. Therefore, a remand is not necessary in order for the AOJ to initially consider such evidence. In July 2009, the Veteran submitted a certificate of his completion of a one week course entitled "Ships Landing Party-1" in May 1966. The Veteran contended that the certificate showed that the on-shore training was at a facility in Da Nang, Vietnam, but no such notation is shown on the certificate. Rather, the certificate shows that the training was performed by the Landing Force Training Unit, a component of the Amphibious Training Command. This training facility was located at the Naval Amphibious Base, Coronado, California. In May 1966, the Veteran was assigned to the crew of USS Walke at the ship's home port in Long Beach, California, and was not deployed to the Western Pacific. It is not credible that this training would be conducted in an overseas, hostile area, and it is not credible that the Veteran, a junior seaman, would be transported to Vietnam for one week of training. It is significantly more likely that the training was performed at the main facility in Coronado near his ship's homeport, consistent with the Veteran's and the ship's location in May 1966. Therefore, as the Veteran's statements are inconsistent with the contemporaneous evidence of record, the Board finds them to be not credible. See Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff'd per curiam, 78 F.3d. 604 (Fed. Cir. 1996) (in weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness). Therefore, the Board finds that the Veteran was not present on the landmass of Vietnam. Consequently, the Board concludes that the Veteran was not present on the landmass of Vietnam and did not serve on a ship that docked on the shores or piers of Vietnam, operated temporarily in the Vietnam inland waterways, or operated on close coastal waters for extended periods and, therefore, is not presumed to have been exposed to herbicides. Accordingly, presumptive service connection for diabetes mellitus type II as related to such exposure is not warranted. The Veteran alleges that service connection for peripheral neuropathy of the bilateral upper and lower extremities is warranted as secondary to diabetes mellitus type II. In this regard, he does not allege, nor does the record reflect, that he first manifested peripheral neuropathy during service or that such is otherwise related to service on a direct basis. Specifically, the Veteran's service treatment records are negative for complaints, treatment, or diagnoses of peripheral neuropathy. Rather, the Veteran has claimed that he currently has peripheral neuropathy as a result of diabetes mellitus type II. See Robinson, supra. However, as discussed previously, the Veteran is not entitled to service connection for diabetes mellitus type II. As such, the Board finds that under the law, the Veteran lacks legal grounds to establish entitlement to service connection for peripheral neuropathy as secondary to such disease. See Sabonis v. Brown, 6 Vet. App. 426 (1994). In Sabonis, the Court held that in cases in which the law and not the evidence is dispositive, a claim for entitlement to VA benefits should be denied or the appeal to the Board terminated because of the absence of legal merit or the lack of entitlement under the law. Insofar as service connection is not in effect for the disability claimed by the Veteran to have proximally caused or aggravated his peripheral neuropathy, service connection on a secondary basis is not applicable under the law. As there is no legal entitlement, the claim of entitlement to service connection for peripheral neuropathy as secondary to diabetes mellitus type II is without legal merit. Id. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claims of entitlement to service connection for diabetes mellitus type II and peripheral neuropathy. As such, that doctrine is not applicable in the instant appeal, and his claims must be denied. 38 U.S.C.A. § 5107. ORDER Service connection for diabetes mellitus type II is denied. Service connection for peripheral neuropathy of the bilateral upper and lower extremities is denied. REMAND Regarding the Veteran's claim of entitlement to service connection heart disease, the Board finds that a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide his claims so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran has alleged that his heart disease is related to in-service herbicide exposure or as secondary to diabetes mellitus type II or service-connected PTSD. In this decision, the Board denied service connection for diabetes mellitus. Therefore, service connection for heart disease as secondary to diabetes is not available. Moreover, as the Board determined that the Veteran was not exposed to herbicides during his military service, presumptive service connection for ischemic heart disease is not warranted. However, as relevant to his contention that his heart disease is secondary to his PTSD, the Board finds that further development is warranted. Specifically, in December 2010, a VA physician did not review the claims file but did review VA electronic medical records. The physician noted the previous diagnoses of coronary artery disease as well as the Veteran's history of tobacco use, and his family history of coronary artery disease and hypertension. The physician cited internet sites of the American Heart Association, American College of Cardiology, and the Joint National Committee on Prevent, Detection, Evaluation, and Treatment of High Blood Pressure and concluded that it was less likely than not that the Veteran's heart disease was caused or aggravate by PTSD. The physician concluded that many other risk factors were present in the Veteran's history. The physician noted that PTSD was not a risk factor in the Framingham risk score and that she was unaware of any medical literature that indicated a causal association between PTSD and coronary artery disease. In a May 2013 brief to the Board, the Veteran's representative cited several sources of medical information on the relationship between PTSD and cardiovascular diseases. The cited sources are: Cecil Textbook of Medicine, 253 (22nd Ed., 2004); An internet article sponsored by Harvard University referring to an August 2006 edition of the The Harvard Heart Letter (article available at http://www.health.harvard.edu/press_releases/ptsd-heart-disease); The ScienceDaily, a news web site article dated November 10, 1999 (address not provided); Joseph Boscarino, "PTSD Causes Early Heart Disease Death," published in Psychometric Medicine (secondary cite only); and L. Kraviz, "Sleep Deprivation: Cognitive Function and Health Consequences," IDEA Fitness Journal, 9(2), 18-21 (Feb. 2012). The Board concludes that an addendum VA opinion is necessary to decide the claim for service connection for heart disease as secondary to PTSD. The Board does not assess the relevance, degree of competence, credibility, and probative weight that may be associated with the Veteran's cited sources or whether they apply in the Veteran's case. However, the citations do indicate the existence of some medical literature associating PTSD and heart disease. Therefore, an addendum opinion from the VA physician who reviewed the case in December 2010, if available, or an additional opinion from another VA physician is necessary to decide the claim. Accordingly, the case is REMANDED for the following action: 1. Return the claims file to the December 2010 VA examiner. The claims file and a copy of this Remand must be made available to the examiner. The examiner shall note in the examination report that the claims folder and the Remand have been reviewed. If the December 2010 VA examiner is not available, the claims file should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. After a review of the claims file, to specifically include the sources of medical literature cited by the Veteran's representative, if possible, the examiner should again address whether it is at least as likely as not that the Veteran's PTSD caused OR aggravated his heart disease. In rendering such opinion, the examiner should discuss the supporting literature noted by the Veteran's representative, to the extent possible. Any opinion expressed should be accompanied by a supporting rationale. 2. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or 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). ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs