Citation Nr: 1324371 Decision Date: 07/31/13 Archive Date: 08/07/13 DOCKET NO. 07-10 430 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for tinnitus, to include as due to an undiagnosed illness. 2. Entitlement to service connection for bronchitis, to include as due to an undiagnosed illness. 3. Entitlement to service connection for a stomach disorder, including gastritis, to include as due to an undiagnosed illness. 4. Entitlement to service connection for residuals of bilateral big toe fractures, to include as due to an undiagnosed illness. 5. Entitlement to service connection for headaches, to include as due to an undiagnosed illness. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD K. Fitch, Counsel INTRODUCTION The Veteran had active service from May 1999 to May 2004, including service in the Persian Gulf. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington. The Veteran's claims file was subsequently transferred to the RO in Denver, Colorado. In an April 2007 VA Form 9 (Appeal to Board of Veterans' Appeals), the Veteran requested a Board hearing at the RO. The Veteran was scheduled for such a hearing in November 2010, but failed to report as scheduled. The Veteran's hearing request is considered withdrawn. See 38 38 C.F.R. § 20.704 (2011). This case was previously before the Board in August 2010, February 2011, and October 2012. The case has been returned to the Board for further appellate consideration. In March 2013, the RO granted entitlement to service connection for lumbar strain with intervertebral disc syndrome and mild right-sided radiculopathy, and also entitlement to service connection for lumbar radiculopathy, right side, secondary to service-connected intervertebral disc syndrome. Those matters are no longer on appeal. The Board notes that, in addition to the Veteran's claims file, the Veteran also has a Virtual VA paperless claims file, which is a highly secured electronic repository that is used to store and review documents involved in the claims process. The Board has reviewed the contents of the paperless file as well as the Veteran's claims file and will proceed with review of the claims based upon all relevant evidence. The issue of entitlement to service connection for a stomach disorder, to include diarrhea, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's active service included a period of service in the Persian Gulf theater of operations. 2. The Veteran has had definitive clinical diagnoses of acute bronchitis, resolved without residual, acute gastritis, resolved, acute gastroenteritis, heartburn, diarrhea, hallux valgus, tension headaches, and tinnitus. 3. The medical evidence indicates that the Veteran has no current disability related to acute bronchitis, acute gastritis, or acute gastroenteritis. 4. The medical evidence indicates that heartburn, hallux valgus, tension headaches, and tinnitus did not have their onset in active military service or within one year of service. CONCLUSION OF LAW 1. Acute bronchitis, acute gastritis, acute gastroenteritis, heartburn, hallux valgus, tension headaches, and tinnitus, to include as due to an undiagnosed illness, were not incurred, nor are such disabilities presumed to have been incurred in active duty. 38 U.S.C.A. § 1111, 1112, 1113, 1117, 1131, 1137 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303, 3.304(b), 3.307, 3.309, 3.317 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VCAA. As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Proper notice from VA must inform the claimant of any information and medical or lay 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 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent letters dated in August 2005, March 2010, February 2011, and November 2012 that provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. The letters also explained what type of information and evidence was needed to establish a disability rating and effective date. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, his statements in support of the claim are of record. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Service connection. Applicable law provides that service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may also be granted for certain chronic diseases, such as arthritis, when the disease is manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that a disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995); 38 C.F.R. § 3.303(a). The existence of a current disorder is the cornerstone of a claim for VA disability compensation. Degmetich v. Brown, 104 F. 3d 1328 (1997) (interpretation of 38 U.S.C.A. § 1110 and 38 U.S.C.A. § 1131 as requiring the existence of a present disorder for VA compensation purposes cannot be considered arbitrary and decision based on that interpretation must be affirmed); Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). That a condition or injury occurred in service alone is not enough. There must be disability resulting from that condition or injury. In the absence of proof of a present disability, there can be no valid claim or the grant of the benefit. Rabideau v. Derwinski, 2 Vet. App. 141 (1992); see also McLain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the requirement that a claimant have a current disability before service connection may be awarded for that disability is also satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even if no disability is present at the time of the claims adjudication). Under § 3.303(b), an alternative method of establishing the second and/or third element is through a demonstration of continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (38 C.F.R. § 3.303(b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a)). Continuity of symptomatology may establish service connection where a chronic disease under 38 C.F.R. § 3.309(a) shown as such in service or within the presumptive period, manifests at a later date. 38 C.F.R. § 3.303(b). Continuity of symptomatology is required where the condition noted during service or the presumptive period is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. Id. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. In this regard, the Board notes that lay persons may provide evidence of diagnosis and nexus under 38 U.S.C.A. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (vacating a decision that stated categorically that a valid medical opinion was required to establish nexus and that a lay person was not competent to provide testimony); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (lay evidence can be competent and sufficient to establish a diagnosis of the lay person is reporting a contemporaneous medical diagnosis); see also Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection). In addition, service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). It is the Board's responsibility to evaluate the entire record on appeal. 38 U.S.C.A. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, reasonable doubt will be resolved in each such issue in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. An appellant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. To deny a claim on its merits, the evidence must preponderate against the claim. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Alemany v. Brown, 9 Vet. App. 518 (1996). Also, service connection may be presumed for chronic disability due to undiagnosed illness of a Veteran who served in the Southwest Asia Theater of operations during the Persian Gulf War when there are objective indications of a chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as fatigue, signs or symptoms involving the skin, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper and lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. The illness must become manifest during either active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more, under the appropriate diagnostic code of 38 C.F.R. § Part 4, not later than December 31, 2016. By history, physical examination, and laboratory tests, the disability cannot be attributed to any known clinical diagnosis. There must be objective signs that are perceptible to an examining physician and other non-medical indicators that are capable of independent verification. There must be a minimum of a six-month period of chronicity. There must be no affirmative evidence that relates the undiagnosed illness to a cause other than being in the Southwest Asia Theater of operations during the Persian Gulf War. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317; see 71 Fed. Reg. 75,669 (Dec.8, 2006). If signs or symptoms have been medically attributed to a diagnosed (rather than undiagnosed) illness, the Persian Gulf War presumption of service connection does not apply. VAOPGCPREC 8-98. For purposes of this Persian Gulf War illness presumption, a qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) the following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) irritable bowel syndrome; or (4) any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness; or (C) any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A. § 1117(d) warrants a presumption of service-connection. 38 C.F.R. § 3.17(a)(2)(i). For purposes of this section, the term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.17(a)(2)(ii). For purposes of this section, "objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.17(a)(3). For purposes of this section, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § .17(a)(4). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see Gilbert v. Derwinski, 1 Vet. App. 49,53 (1990); see also 38 C.F.R. § 3.102. In this case, it has been noted by previous Board remands that the Veteran had noise exposure during service. Likewise, the Veteran's service treatment records indicate that the Veteran was treated for bronchitis, gastritis, low back strain, headaches, and for painful feet and toes during the course of his military service. Because it was unclear whether the Veteran had current disabilities related to his claims and whether such disabilities had their onset in service, this matter was remanded in order to afford the Veteran a VA examination in connection with his claims. The Veteran was examined by VA in January 2013. The examiner indicated that the Veteran's claims file had been reviewed in connection with the examination and report. The Veteran was diagnosed with acute bronchitis, resolved without residuals, acute gastritis, resolved, acute gastroenteritis, hallux valgus, tension headaches, heartburn, and tinnitus. The examiner stated that each of the claimed conditions was a disease that had a clear and specific etiology and diagnosis. With respect to bronchitis, the examiner noted that the Veteran had been diagnosed with bronchitis and early pneumonia in service. The Veteran was sick for two weeks, but reported a good recovery. The examiner found that the Veteran had not had any major respiratory illnesses since that time. The Veteran stated that did not feel that he had any major residuals from this condition. The examiner stated that the Veteran had a history of bronchitis in service that had since resolved without residual. There were no findings of lung disease and the examination was normal. In addition, chest x-rays showed no evidence of active disease in the chest. With respect to the Veteran's gastritis and stomach claim, the Veteran was diagnosed with acute gastritis, resolved, acute gastroenteritis, and heartburn. The Veteran remembered having some mild self-limiting stomach illnesses in service and heartburn during and after service. The examiner also noted that the Veteran experienced stomach cramping with associated diarrhea about once a month. The examiner stated that these conditions were less likely related to a specific exposure event experienced by the Veteran during service in Southwest Asia. In addition, heartburn was not linked to the Veteran's active military service. The examiner stated that there was no evidence that a heartburn condition had its onset during service as the service records are silent for complaints of recurrent heartburn. With respect to the gastritis and gastroenteritis, the examiner stated that such condition(s) were at least as likely as not caused by or as a result of the Veteran's active military service. However, the examiner also found that there did not appear to be any current chronic disabling condition. With respect to the Veteran's toe and headache claims, the examiner rendered diagnoses of hallux valgus and tension headaches. The Veteran reported that he developed pain in the great toes with running during service around June 1999. He did not seek medical attention in service, but that he continues to have pain in the great toes and with walking since that time. The Veteran reported string to have headaches in 2001 that have recurred intermittently since that time. The examiner noted that the Veteran had two types of headaches: one in the sinus area and the other, tension headaches. The examiner stated that these conditions were less likely related to a specific exposure event experienced by the Veteran during service in Southwest Asia. The examiner also stated that the conditions were less likely as not a result of in-service events or injuries. In this regard, the examiner noted that there was a single complaint of foot pain with great toe pain in 1999 and the remaining records are silent for any complaints of foot problems and all examinations were negative for any abnormality of the feet or toes. The examiner stated that he could not find evidence that the foot condition found on examination had its onset in the military. With respect to the headaches , the examiner stated that the medical review record did not show any complaints of or treatment for headaches and that the service treatment records were silent for headaches similar to those described above. Finally, with respect to the Veteran's to claim, the January 2013 examiner diagnosed the Veteran with tinnitus. After a review of the claims file, however, the examiner found that the condition was less likely than not (less than 50% probability) caused by or a result of military noise exposure. In this regard, the examiner stated that the description of tinnitus onset and resolution as well as the frequency of its occurrence makes the origin less likely as not noise related. The examiner also noted that there was no report of tinnitus in his post-deployment survey. The examiner indicated that intermittent Eustachian tube dysfunction or bronchitis may be contributing to his complaints of tinnitus. The Veteran's outpatient treatment records were reviewed, but indicated no diagnoses or treatment related to the Veteran's claimed conditions. The Board has considered the totality of the record and finds that the weight of the evidence is against the Veteran's claims. First, each of the claimed disabilities has been objectively diagnosed with a known diagnosable condition. As such, the Veteran does not met the criteria under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 for undiagnosed illness. Next, the January 2013 examiner found that the Veteran did not have current chronic bronchitis or gastritis and gastroenteritis conditions. And without a current chronic disability diagnosed within the appeal period, there can be no entitlement to service connection. As noted above, the existence of a current disorder is the cornerstone of a claim for VA disability compensation. Degmetich v. Brown, 104 F. 3d 1328 (1997); Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). In the absence of proof of a present disability, there can be no valid claim or the grant of the benefit. Rabideau v. Derwinski, 2 Vet. App. 141 (1992); see also McLain v. Nicholson, 21 Vet. App. 319, 321 (2007). Finally, with respect to heartburn, hallux valgus, tension headaches, and tinnitus, while these conditions were diagnosed, the January 2013 examinations indicated that these conditions were not related to the Veteran's military service. The Board notes that the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches. The credibility and weight to be attached to these opinions is within the province of the Board. Guerrieri v. Brown, 4 Vet. App. 467 (1993). The Board must account for evidence it finds persuasive or unpersuasive, and provide reasons for rejecting material evidence favorable to the claim. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). In determining the weight assigned to this evidence, the Board also looks at factors such as the health care provider's knowledge and skill in analyzing the medical data. Guerrieri v. Brown, 4 Vet. App. 467 (1993); Black v. Brown, 10 Vet. App. 279 (1997). In this case, the Board finds that the opinions of the VA examiners in this case to be most persuasive, based as they were on examinations of the Veteran and his claims file. In addition, the Board notes that the Veteran has contended on his own behalf that his claimed disabilities are related to his service. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts that the lay witness observed and is within the realm of his or her personal knowledge. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir. 2007) (noting that lay testimony may be competent to identify a particular medical condition). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). However, while VA must consider lay evidence, it may give it whatever weight it concludes the evidence is entitled to, and a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require VA to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010); see also See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (Lance, J. concurring) ("the Board should avoid overbroad statements about the competence of laypersons and should carefully distinguish its treatment of lay testimony of symptoms and its analysis of lay competence on issues of diagnosis or causation"). Although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Board finds that the diagnosis and etiology of the Veteran's disorders are complex medical questions, beyond the competency of a layperson. The Board further finds that the question regarding the relationship between such disabilities and military service to be complex in nature. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Therefore, as the Veteran has only provided his own conclusory statements regarding diagnosis and causation, the Board finds that the Veteran's statements to be of little probative value as he is not competent to opine on such complex medical questions. In summary, the Board concludes that the preponderance of the evidence is against the Veteran's claims. The Board may not base a decision on its own unsubstantiated medical conclusions but, rather, may reach a medical conclusion only on the basis of independent medical evidence in the record. Hensley v. Brown, 5 Vet. App. 155 (1993). Because the preponderance of the evidence is against the claims, the claims must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for acute bronchitis, to include as due to an undiagnosed illness is denied. Service connection for a gastrointestinal disorder, including acute gastritis, acute gastroenteritis, and heartburn, to include as due to an undiagnosed illness is denied. Service connection for hallux valgus, to include as due to an undiagnosed illness is denied. Service connection for tension headaches, to include as due to an undiagnosed illness is denied. Service connection for tinnitus, to include as due to an undiagnosed illness is denied. REMAND Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. VA has a duty to make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a); 38 C.F.R. § 3.159(c), (d). With respect to the Veteran's diagnosed diarrhea, the Board notes that the January 2013 VA examiner indicated that the condition was less likely the result of military service as the Veteran reported onset of the condition prior to deployment and that service treatment records were silent for any complaints of intermittent diarrhea. In this regard, the Board notes that when no preexisting medical condition is noted upon entry into service, a Veteran is presumed to have been sound upon entry. 38 U.S.C.A. § 1111 (West 2002); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The presumption of soundness applies if a Veteran's congenital disease is not noted at entry. See Quirin, 22 Vet. App. at 396-97; Monroe, 4 Vet. App. at 515. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the disability was both preexisting and not aggravated by service. Wagner, 370 F.3d at 1096; Bagby, 1 Vet. App. at 227. Accordingly, "[o]nce the presumption of soundness applies, the burden of proof remains with the Secretary on both the preexisting and the aggravation prong; it never shifts back to the claimant. In particular, even when there is clear and unmistakable evidence of preexistence, the claimant need not produce any evidence of aggravation in order to prevail under the aggravation prong of the presumption of soundness ... the burden is not on the claimant to show that his disability increased in severity; rather, it is on VA to establish by clear and unmistakable evidence that it did not or that any increase was due to the natural progress of the disease." Horn v. Shinseki, 25 Vet. App. 231, 235 (2012). This burden must be met by affirmative evidence demonstrating that there was no aggravation. See Id. The burden is not met by finding that the record contains insufficient evidence of aggravation. See Id. As there is no specific finding in the record related to a preexisting diarrhea condition, this matter must be remanded for additional opinion. When medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). Assistance by VA includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Accordingly, the case is REMANDED for the following action: 1. If the individual who conducted the January 2013 VA examination is available, forward the entire claims file, including a copy of this remand, to him for an addendum report in response to the following questions. Review of the claims file should be noted in the examination report. If any further testing or diagnostic studies are necessary prior to offering such opinions, they should be completed. The examiner should respond to the following questions: Please state the specific diagnosis related to the identified diarrhea condition noted in the January 2013 VA examination. Please state whether the Veteran diagnosed diarrhea condition clearly and unmistakably both (i) preexisted the Veteran's entry into active service, and (ii) was not aggravated, beyond the normal progress of the disorder, during or as a result of active service (i.e., that it clearly and unmistakably did not increase or that any increase was clearly and unmistakably due to the natural progress of the disease). If the diagnosed diarrhea disability did not clearly and unmistakably preexist the Veteran's service, is at least as likely as not (probability of 50 percent or more) that any such disorder was incurred in or aggravated by any incident, disease, or injury during service? In offering any opinion, the examiner must consider the Veteran's lay statements regarding the incurrence of his claimed disorder and the continuity of symptomatology. A complete rationale for all opinions is requested. If the examiner finds that he or she cannot provide a nexus opinion without resorting to speculation, the examiner must explain why he or she is unable to provide an opinion without speculation, and sufficiently explain the reasons for that inability. 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). ____________________________________________ THOMAS H. O'SHAY Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs