Citation Nr: 1322052 Decision Date: 07/10/13 Archive Date: 07/18/13 DOCKET NO. 03-34 207A ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for a right leg disorder. 2. Entitlement to service connection for a left leg disorder. 3. Entitlement to an initial rating in excess of 10 percent for gastroesophageal reflux disease. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. Fleming, Counsel INTRODUCTION The Veteran had active military service from November 2000 to June 2002. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a June 2002 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In that decision, the RO denied the Veteran's claims for service for right and left leg disorders and granted service connection for gastroesophageal reflux disease, assigning an initial 10 percent disability rating. The Veteran perfected an appeal to the Board, which denied the Veteran's claim for a higher rating in an August 2011 decision. (At that time, the Board also remanded the Veteran's claims of service connection for right and left leg disorders.) In July 2012, the Veteran's representative and VA's Office of General Counsel filed a joint motion requesting that the United States Court of Appeals for Veterans Claims (Court) vacate the Board's decision concerning the claim for a higher rating and remand the matter to the Board for further development and readjudication. That same month, the Court granted the joint motion and remanded the case to the Board for compliance with the terms of the joint motion. The basis for the joint motion included the Board's failure to consider whether there are other Diagnostic Codes under which the Veteran's gastroesophageal reflux disease should be considered. As the appeal of the Veteran's claim for an initial rating in excess of 10 percent for gastroesophageal reflux disease emanates from the Veteran's disagreement with the initial rating assigned following the grant of service connection, the Board has characterized the claim as for a higher initial rating in accordance with Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Veteran testified before the undersigned Veterans Law Judge at a videoconference hearing in August 2006. A transcript of the hearing has been associated with the Veteran's claims file. When this case was before the Board in October 2006, claims of service connection for right and left knee disorders were on appeal. Subsequently, by a July 2009 rating decision, the agency of original jurisdiction (AOJ) granted service connection for degenerative joint disease and patellofemoral joint syndrome. Consequently, the service connection knee claims have been satisfied. Service connection was also granted for a left leg disorder (greater trochanteric bursitis with iliotibial banditis); however, it appears that the Veteran is pursuing a claim for disability beyond this left leg disability. Consequently, further action will be taken by the Board. The decision below addresses the Veteran's claim for an initial rating in excess of 10 percent for gastroesophageal reflux disease. The issues of service connection for right and left leg disorders are addressed in the remand that follows the decision. FINDING OF FACT The Veteran's service-connected gastroesophageal reflux disease is manifested by substernal pain, pyrosis, and regurgitation; persistently recurring epigastric distress with considerable impairment of health is not shown. CONCLUSION OF LAW The criteria for a an initial rating in excess of 10 percent for service-connected gastroesophageal reflux disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.114, Diagnostic Code 7346 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist At the outset, the Board notes the enactment of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), in November 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2012). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). (The Board notes that 38 C.F.R. § 3.159 was revised, effective May 30, 2008, during the pendency of the appeal. See 73 Fed. Reg. 23353-56 (Apr. 30, 2008). The amendments apply to applications for benefits pending before VA on, or filed after, May 30, 2008. The amendments, among other things, removed the notice provision requiring VA to request the Veteran to provide any evidence in the Veteran's possession that pertains to the claim. See 38 C.F.R. § 3.159(b)(1).) In this case, the Board finds that all notification and development action needed to arrive at a decision on the claim decided herein has been accomplished. In this respect, through October 2003, May 2005, and August 2009 notice letters, the Veteran received notice of the information and evidence needed to substantiate her claim. Thereafter, the Veteran was afforded the opportunity to respond. Hence, the Board finds that the Veteran has been afforded ample opportunity to submit information and/or evidence needed to substantiate her claim. The Board also finds that the October 2003, May 2005, and August 2009 notice letters satisfy the statutory and regulatory requirement that VA notify a claimant what evidence, if any, will be obtained by the claimant and which evidence, if any, will be retrieved by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). In the letters, the RO also notified the Veteran that VA was required to make reasonable efforts to obtain medical records, employment records, or records from other Federal agencies. The RO also requested that the Veteran identify any medical providers from whom she wanted the RO to obtain and consider evidence. 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. See Pelegrini v. Principi, 18 Vet. App. 112, 121 (2004). See also Notice and Assistance Requirements and Technical Correction, 73 Fed. Reg. 23,353 (Apr. 30, 2008) (to be codified at 38 C.F.R. § 3.159) (removing the prior requirement that VA specifically ask the claimant to provide any pertinent evidence in his possession). These requirements were met by the aforementioned October 2003, May 2005, and August 2009 notice letters. The Board further notes that notice regarding an award of an effective date and rating criteria was provided in the August 2009 letter. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). The Board thus finds that "the appellant [was] provided the content-complying notice to which [s]he [was] entitled." Pelegrini, 18 Vet. App. at 122. In this regard, the more detailed notice requirements set forth in 38 U.S.C.A. §§ 7105(d) and 5103A have been met. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). In addition, the Veteran was given the opportunity to respond following the October 2003, May 2005, and August 2009 notice letters. Nothing about the evidence or any response to the RO's notification suggests that the case must be re-adjudicated ab initio to satisfy the requirements of the VCAA. The Board also points out that there is no indication that any additional action is needed to comply with the duty to assist in connection with the claim decided herein. Records of the Veteran's ongoing treatment at multiple VA medical facilities, as well as with private treatment providers, have been obtained and associated with the claims file. Records from the Veteran's award of SSA benefits have also been associated with the claims file. In addition, the Veteran has been given the opportunity to submit evidence, and she and her representative have provided written argument in support of her claim. The Veteran has also testified before the undersigned Veterans Law Judge at a videoconference hearing in August 2006. Neither the Veteran nor her representative has otherwise identified, and the record does not indicate, existing records pertinent to the claim decided herein that need to be obtained. Additionally, the Veteran was afforded VA examinations in February 2003, January 2005, December 2006, and January 2007, the reports of which are of record. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As noted below, the Board finds that the VA examinations obtained in this case are sufficient, as they are predicated on consideration of the medical records in the Veteran's claims file, as well as specific examination findings. They consider the statements of the Veteran, and provide a rationale for the findings made, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination as to the issue decided herein has been met. 38 C.F.R. § 3.159(c)(4). Under these circumstances, the Board finds that VA has complied with all duties to notify and assist required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159. II. Analysis The Veteran contends that her gastroesophageal reflux disease has been more disabling than indicated by the assigned rating. She therefore contends that a higher rating is warranted. Disability evaluations are determined by comparing a Veteran's symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher of the two evaluations is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). The Veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1 (2012); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In cases where the original rating assigned is appealed, consideration must be given to whether the Veteran deserves a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). The relevant medical evidence of record concerning the Veteran's claim for an initial rating in excess of 10 percent for GERD consists of reports of VA examinations conducted in February 2003, January 2005, and December 2006, as well as ongoing treatment the Veteran has received from both VA and private treatment providers. At the February 2003 examination, the Veteran reported that she suffered from a burning substernal sensation, nausea, and occasional awakening from sleep with difficulty breathing. The Veteran also complained of belching, pharyngitis, and regurgitation, although she denied abdominal pain, vomiting, dysphagia, or changes in bowel movements. She was noted to be using daily medication, and her weight was noted to be stable. The examiner diagnosed her with GERD. Similarly, at the January 2005 VA examination, the Veteran complained of a burning sensation in the epigastric area that she experienced daily, as well as waking up choking three to four times per week. The Veteran also complained of experiencing regurgitation approximately four times weekly and stated that she experienced pharyngeal irritation, belching, hoarse voice, and nausea after meals. She denied experiencing diarrhea, vomiting, or dysphagia and noted that her weight and appetite were stable. The examiner conducted physical examination and diagnosed the Veteran with GERD with daily moderate symptoms. At her December 2006 VA examination, the Veteran was noted to complain of chronic dyspepsia, although the examiner noted that she had experienced no weight loss or blood in the stool. The examiner noted that the Veteran had no H. pylori and no Barrett's esophagus and diagnosed her with dyspepsia and anxiety. The examiner specifically noted that although the Veteran complained of "severe symptoms of reflux," physical examination and testing revealed only mild injury to her esophagus and "an almost normal acid regurgitation study." The examiner attributed the Veteran's complaints to her PTSD symptomatology rather than physical manifestations of GERD. Report of the Veteran's ongoing treatment at VA facilities reflects that she was seen in November 2004 for multiple medical complaints but was found at that time to have "no warning signs of worsening GERD." In so finding, her treatment provider noted that the Veteran's weight and hemoglobin were stable with no blood pressure fluctuation, melena, or other worsening symptoms. The Veteran underwent an upper GI endoscopy in March 2005, which revealed no abnormalities. Further testing in October 2005 revealed he Veteran to have reflux and "chronic inflammation" of the gastrointestinal tract. At a psychological treatment visit in July 2006, the Veteran's treatment provider noted that her complaints of nausea were likely due to her posttraumatic stress disorder and not to her diagnosis of GERD. At a November 2006 visit, the Veteran noted that she experienced bloating when stressed but that her symptoms of nausea had lessened following a hysterectomy. Similarly, the Veteran was seen in March 2007 to complain of feeling bloated and nauseous after eating. At a September 2007 treatment visit, the Veteran complained of ongoing nausea and occasional vomiting once every one to two weeks but denied hematemesis or melena. At that time she was noted to have experienced a gradual weight gain over the past few years. No signs of anemia, pain, or tenderness in the abdomen were noted. The Veteran was instructed to continue with medications and avoid eating prior to sleep. At her August 2006 hearing before the undersigned Veterans Law Judge, the Veteran stated that she had regurgitation that affected her, especially at night or while lying down and that she occasionally woke from sleep gasping for air. She indicated that she experienced nausea and had restricted her diet to address her GERD symptoms. She further stated that her need for medication was continuous to treat the symptoms of her GERD, but denied experiencing vomiting on a regular basis. The Veteran has reiterated these contentions in multiple written statements to VA in which she complains of experiencing acid reflux and inflammation of her digestive tract. The RO has indicated that it evaluated the Veteran's GERD by analogy to hiatal hernia under Diagnostic Code 7399-7346. 38 C.F.R. § 4.114, Diagnostic Code 7346 (2012). The use of Diagnostic Code 7399 represents an unlisted disability that requires rating by analogy to one of the disorders rated under 38 C.F.R. § 4.114. See 38 C.F.R. § 4.27 (2012) (hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen). When an unlisted condition is encountered, it is permissible to rate it under a closely related disease or injury to which not only the functions affected, but also the anatomical location and symptomatology, are closely analogous. 38 C.F.R. § 4.20 (2012.) Under Diagnostic Code 7346, a 60 percent rating is assigned when there are symptoms of pain, vomiting, material weight loss and hematemesis, or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. A 30 percent rating is assigned when there is persistently recurrent epigastric distress with dysphagia (difficulty swallowing), pyrosis (heartburn), and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent rating requires two or more of the symptoms for the 30 percent evaluation of less severity. 38 C.F.R. § 4.114, Diagnostic Code 7346. Following a review of the examination reports and noted findings, the Board finds that an initial rating in excess of 10 percent for the Veteran's GERD is not warranted at any time during the claim period. In this regard, the Board acknowledges that the Veteran has consistently stated that she experiences regurgitation and heartburn with occasional substernal pain. Similarly, the February 2003, January 2005, and December 2006 VA examination reports reflect that the Veteran's GERD has been manifested by pyrosis and regurgitation, as well as substernal pain. See 38 C.F.R. §§ 3.102, 4.3, 4.114, Diagnostic Code 7346. However, persistently recurrent epigastric distress has not been evidenced by the VA examination or the Veteran's testimony; nor has the Veteran been shown to have considerable impairment of health due to her GERD symptomatology. In that connection, the Board notes that the February 2003, January 2005, and December 2006 VA examiners all found specifically that the Veteran was experiencing no weight loss or adverse effect on her health due to her GERD. Additionally, hematemesis or melena has not been shown; nor has the Veteran demonstrated dysphagia, pyrosis, or frequent vomiting at any time during the claim period. Consequently, the Board concludes that initial rating in excess of 10 percent is not warranted for the Veteran's service-connected GERD at any time since the award of service connection. As noted above, the parties to the Joint Motion indicated that the Board had erred by failing to consider other Diagnostic Codes that could potentially be applicable to the Veteran's GERD in the absence of a Diagnostic Code specifically addressing that disorder. However, the Board finds that other Diagnostic Codes under 38 C.F.R. § 4.114, governing disorders of the digestive system, do not reflect the Veteran's disability better than Diagnostic Code 7346, governing hiatal hernia, and are thus not appropriate Diagnostic Codes under which to evaluate the Veteran's service-connected GERD. In the joint motion, the parties point as an example to Diagnostic Code 7305, governing duodenal ulcers. However, the Board finds that this Diagnostic Code is inapplicable to the Veteran's GERD, given that 38 C.F.R. § 4.20 specifies, when rating disorders by analogy, that not only the functions affected but also the anatomical location and symptomatology be closely analogous. In this case, the Board finds that Diagnostic Code 7305 is inapplicable in that it evaluates symptoms caused by an ulcer of the duodenum, not the stomach or esophagus; thus, the anatomical locations are not analogous. Similarly, the Board finds that Diagnostic Codes under 38 C.F.R. § 4.114 governing disorders of the intestines, liver, pancreas, and gall bladder are inappropriate Diagnostic Codes with which to evaluate the Veteran's GERD under the provisions of 38 C.F.R. § 4.20. The Board further notes that certain Diagnostic Codes under 38 C.F.R. § 4.114 address the gastric and esophageal systems, making them at least potentially applicable under 38 C.F.R. § 4.20 when rating disorders by analogy. However, the Veteran has at no time displayed or claimed to experience stricture or spasm of the esophagus, rendering ratings under Diagnostic Codes 7203 and 7204 inappropriate. Similarly, no peritoneal adhesions have been shown, and the Veteran has not displayed any obstruction or other symptoms such as delayed motility of barium meal and pulling pain in the peritoneal region; thus, rating under Diagnostic Code 7301 is not appropriate when evaluating the Veteran's GERD. In addition, the Board finds that Diagnostic Code 7307, evaluating gastritis, is not fitting for evaluating the Veteran's GERD, as she has not displayed eroded or ulcerated areas or hemorrhages of the stomach to warrant a disability rating under that Diagnostic Code. She has further not undergone a gastrectomy, rendering Diagnostic Code 7308, concerning postgastrectomy syndrome, inapplicable. In so finding, the Board again notes that 38 C.F.R. § 4.20 requires that not only the functions affected, but also the anatomical location and symptomatology, be closely analogous when relying on a Diagnostic Code to rate by analogy. In this case, the identified Diagnostic Codes simply do not provide as close a similarity to the anatomical location, symptomatology, and affected functions as does Diagnostic Code 7346 governing hiatal hernia. Thus, the Board finds that Diagnostic Code 7346 provides the most fitting criteria under which to evaluate the Veteran's GERD. The above determinations are based on consideration of the applicable provisions of VA's rating schedule. The Board also finds that at no time has the disability under consideration been shown to be so exceptional or unusual as to warrant consideration of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). Here, there is an absence of evidence of marked interference with employment (i.e., beyond that contemplated in the assigned evaluation), frequent periods of hospitalization, or evidence that the Veteran's service-connected GERD-without consideration of other disabilities-has rendered impractical the application of the regular schedular standards. Her symptoms are all specifically contemplated by the criteria discussed above. Thus, the criteria for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Furthermore, it bears emphasis that the schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. Generally, the degrees of disability specified in the rating schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1 (2012). Thus, based on the record before it, the Board does not find that the medical evidence demonstrates any unusual disability with respect to the claim that is not contemplated by the rating schedule. The very symptoms the Veteran experiences are all addressed by the rating schedule. Thun v. Peake, 22 Vet. App. 111 (2008). As a result, the Board concludes that a remand to the RO for referral of the rating issue to the VA Central Office for consideration of extra-schedular evaluation is not warranted. In support of her claim, the Veteran has submitted statements from herself and her husband that describe the daily pain and other symptoms she experiences. The Board recognizes that the Veteran is competent to report on what she sees and feels, and others are competent to report on what they can see. See Layno v. Brown, 6 Vet. App. 465, 471 (1994). Nonetheless, the Board finds more persuasive the opinions provided by the VA examiners regarding the severity of the Veteran's disability, as the VA opinions are based on a review of the evidence and the Veteran's assertions, and because of the examiners' expertise. For all the foregoing reasons, the Board finds that the Veteran's service-connected GERD warrants a rating no higher than the 10 percent initially assigned. 38 C.F.R. §§ 4.3, 4.7, 4.114, Diagnostic Code 7346 (2012). This is so for the entirety of the claim period. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim for increase, that doctrine is not helpful to the Veteran. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER An initial disability rating in excess of 10 percent for gastroesophageal reflux disease is denied. REMAND The Board finds that further action is required before a decision can be reached on the merits of the Veteran's claims for service connection for right and left leg disorders. The United States Court of Appeals for Veterans Claims (Court) has held that a remand by the Board confers on the appellant, as a matter of law, a right to compliance with the remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Court has indicated that, if the Board proceeds with final disposition of an appeal, and the remand orders have not been complied with, the Board itself errs in failing to ensure compliance. Id. As noted in the introduction above, the Board remanded the Veteran's claim in August 2011 for the AOJ to provide the Veteran with VA examination. The Board acknowledges that the AOJ was successful in scheduling at least two VA examinations, which were conducted in May and October 2012. However, during this time period, the AOJ also sent the Veteran multiple notice letters, to addresses in both Illinois and Puerto Rico, that were returned as undeliverable. The record contains a document indicating that the Veteran failed to report to an additional VA examination, which was scheduled in December 2012. The AOJ subsequently sent the Veteran a supplemental statement of the case (SSOC) in December 2012 again denying the claims in part due to the Veteran's failure to report to the December VA examination. This SSOC was sent to an address in Illinois containing an apartment number that was missing from the AOJ's previous attempts at corresponding with the Veteran in Illinois. However, there is no copy in the file of the letter notifying the Veteran of the December 2012 VA examination; nor is there any indication that follow-up with the Veteran was attempted following her failure to report for examination. Moreover, subsequent to the December 2012 missed examination appointment, there are two documents on file, dated in February 2013 and May 2013, indicating that the Veteran's address changed. There is no indication in the record that the scheduling notice concerning the December 2012 VA examination was ever sent to the Veteran at her proper address, which was used for the December 2012 SSOC; nor is it clear that the AOJ has followed up with her at either of her new addresses, as recorded in February 2013 and May 2013. The Veteran is entitled as a matter of law to compliance with the Board's remand instructions. See Stegall, 11 Vet. App. at 271. Therefore, the Board finds that the AOJ must, on remand, complete the development identified in the August 2011 remand and specified below. In particular, regarding the Veteran's service connection claims, the Board acknowledges that the Veteran contends that she has disorders of the legs that she believes are related to service. In particular, the Board notes that the Veteran stated at her August 2006 hearing before the undersigned Veterans Law Judge that she has been diagnosed with restless leg syndrome that she believes is related to service. Regarding diagnosis of the Veteran's claimed leg disabilities, the Board notes that the Veteran has been seen on multiple occasions since service for complaints of muscle pain and spasms in her legs and was assigned "rule-out diagnoses" of restless leg syndrome at January 2006 and April 2006 VA treatment visits. She also underwent physical therapy in 2004 at the Captain James A. Lovell Federal Health Care Center for what was then identified as "myalgia" of her legs. At an October 2007 sleep study conducted at the VA Caribbean Healthcare System in San Juan, Puerto Rico, she was assigned a diagnosis of periodic limb movement disorder. The Veteran has also submitted statements from herself and her husband, and she testified before the undersigned Veterans Law Judge at a hearing in August 2006. A letter from the Veteran's husband dated in March 2006 indicates that he had witnessed her leg cramps and knew she had been prescribed medication to treat restless leg syndrome. Similarly, at her August 2006 hearing, the Veteran contended that she first experienced pain in her legs in service and that she continues to experience the same type of pain in her legs, which she attributed to restless leg syndrome that she believed to be related to service. The Veteran was provided VA examinations in February 2003, January 2005, January 2007, May 2012, and October 2012 pursuant to her claims for service connection. At the February 2003 examination, the examiner noted that the Veteran stated her leg cramps referred to pain in her knees and ankles, not to a separate problem with her legs. No opinion or diagnosis was assigned. At the January 2005 VA examination, the Veteran specifically complained of experiencing spasms in her calf muscles bilaterally that interfered with her sleep; however, the examiner at that time failed to provide a diagnosis related to the Veteran's complaints or address whether any such disability existed or was etiologically linked to her time on active duty. Similarly, at the Veteran's January 2007 VA examination, the examiner addressed only the Veteran's complaints of joint pain in her knees and ankles; no evaluation of any leg cramps or diagnosis of periodic limb movement disorder or other such disability was made or ruled out. Pursuant to the Board's August 2011 remand, the Veteran again underwent VA examination in May 2012. At that time, the examiner diagnosed her with periodic limb movement disorder. The examiner also noted that the Veteran "has had RLS (restless leg syndrome) for 8-9 years" and found that she experienced daytime sleepiness and a sleep disorder due to restless leg syndrome. However, despite also noting the Veteran's complaints that she first experienced symptoms in service, the examiner offered a negative etiological opinion. In so finding, though, the examiner stated only that the cause of her periodic limb movement disorder and restless leg syndrome "is not clear." To obtain clarity concerning the Veteran's diagnoses and their etiology, the AOJ obtained a second VA examination in October 2012. At that time, however, the examiner merely found that, "based on records," he was "unable to determine with greater than 50% probability that the claimant's condition is service connected without resorting to mere speculation." Faced with these obviously deficient findings, the AOJ attempted to schedule the Veteran for yet another VA examination, in order to obtain a proper diagnosis and etiological opinion concerning her claimed leg disorders. The record contains a notation dated in December 2012 that the Veteran failed to report for this additional VA examination. However, as noted above, it is unclear from the record where the notice of said examination was mailed or whether the Veteran actually received notice of the VA examination. Thus, remand is required to schedule the Veteran for another VA examination to address these deficiencies. The chronicity provisions of 38 C.F.R. § 3.303(b) (2012) are applicable where evidence, regardless of its date, shows that a Veteran had a chronic condition in service, or during an applicable presumptive period, and still has such condition. Such evidence must be medical unless it relates to a condition as to which lay observation is competent. Service connection may be established on the basis of § 3.303(b) if the condition is noted during service or during an applicable presumptive period, and if competent evidence, either medical or lay, depending on the circumstances, relates the present condition to continued symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997). In that connection, the Board notes that the Veteran has contended, both to VA and to her treatment providers, that she first experienced problems with her legs in service, which problems have continued to the present. The Board notes that the Veteran is qualified, as a lay person, to report that she suffered pain or injury during service that has continued to the present. See Savage, 10 Vet. App. at 495. However, she is not competent to provide a medical opinion as to the onset of any current disability. See Washington v. Nicholson, 19 Vet. App. 362 (2005); see also Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Once VA undertakes the effort to provide an examination when developing a claim for service connection, even if not statutorily obligated to do so, it must provide an adequate one. See Woehlaert v. Nicholson, 21 Vet. App. 456, 464 (2007), citing Barr, 21 Vet. App. at 311; see also Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence . . . is essential for a proper appellate decision"). Although it appears that the VA examiners conducted a proper evaluation of the Veteran's physical condition at the time, the Board finds that the examiners failed to definitively address whether the Veteran in fact has a current diagnosis of periodic limb movement disorder, restless leg syndrome, or other such disorder that is linked to her time on active duty. This is particularly relevant given that the Veteran has been diagnosed with periodic limb movement disorder by her VA treatment providers in October 2007, and complained of symptoms of the disorder to her January 2005 VA examiner. The Board thus finds that the VA examiners' opinions obtained to date are insufficient. In this case, the Board finds that because the VA examiners' reports did not provide a clear and well-reasoned opinion as to the medical probabilities that the Veteran has a diagnosed periodic limb movement disorder, restless leg syndrome, or any other such disorder that is related to military service, the case must be remanded so that another examination and nexus opinion can be obtained. In view of the foregoing, the case is REMANDED for the following action: 1. The Veteran must be sent a letter requesting that she provide sufficient information and, if necessary, authorization to enable VA to obtain any additional pertinent evidence not currently of record. The letter must be sent to the Veteran's address as listed in the May 2013 update to the file, unless a more recent address is provided by the Veteran. The AOJ must explain the type of evidence VA will attempt to obtain as well as the type of evidence that is the Veteran's ultimate responsibility to submit. 2. After associating with the claims file all available records and/or responses received pursuant to the above-requested development, the Veteran must be scheduled for a VA examination and notified that failure to report to any scheduled examination, without good cause, could result in a denial of her claims. See 38 C.F.R. § 3.655(b) (2012). Notice of the scheduling of the VA examination must be sent to the Veteran's address of record, as noted in the May 2013 update to the file, unless a more recent address is provided by the Veteran. The VA examination is necessary to determine the nature and etiology of any current right or left leg disability shown to be present. The VA examiner must review the Veteran's claims file and medical history, examine the Veteran, and provide an opinion as to whether it is at least as likely as not (i.e., there is at least a 50 percent probability) that any diagnosed right or left leg disorder, including in particular periodic limb movement disorder or restless leg syndrome or the like, is directly related to military service. (Opinion should be provided with respect to each leg.) The reviewer's attention is called to the Veteran's medical history, including in particular her October 2007 diagnosis of periodic limb movement disorder by VA treatment providers. The examiner should specifically outline the reasons to accept or reject the Veteran's assertions that she has experienced such problems continuously since military service. The examiner must review the Veteran's claims file, to include a copy of this remand. A well reasoned etiological opinion must be provided with a detailed explanation for all conclusions reached by the reviewer. Citations to the record or relevant medical principles should be included as necessary to explain the opinion, and a complete rationale must be given for all opinions and conclusions expressed. All appropriate tests and studies must be accomplished, and all clinical findings must be reported in detail. 3. The adjudicator must ensure that the examination report complies with this remand and the questions presented in the examination request. If the report is deficient, it must be returned to the examiner for necessary corrective action, as appropriate. 4. After completing the requested actions and any additional notification and/or development deemed warranted, the claims remaining on appeal must be adjudicated in light of all pertinent evidence and legal authority. If any benefit sought is not granted, the Veteran must be furnished a supplemental statement of the case (SSOC) and afforded the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the appellant until she is notified. The appellant 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 case 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. 2013). ______________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs