Citation Nr: 1324375 Decision Date: 07/31/13 Archive Date: 08/07/13 DOCKET NO. 03-34 974A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a heart disability, to include mitral valve prolapse and cardiomyopathy, to include as secondary to service-connected depression. 2. Entitlement to service connection for a vestibular disorder. 3. Entitlement to service connection for residuals of treatment for exposure to tuberculosis. 4. Entitlement to service connection for residuals of exposure to asbestos. 5. Entitlement to service connection for lumbar spine disabilities. 6. Entitlement to service connection for cervical spine disabilities. 7. Entitlement to service connection for a right shoulder disability. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Mary C. Suffoletta, Counsel INTRODUCTION The Veteran served on active duty from September 1962 to June 1970, and from November 1971 to August 1990. These matters initially came to the Board of Veterans' Appeals (Board) on appeal from an August 2002 rating decision that, in pertinent part, denied service connection for mitral valve prolapse; for a vestibular disorder; for residuals of treatment for exposure to tuberculosis; for residuals of exposure to asbestos; for lumbar spine disabilities; for cervical spine disabilities; and for a right shoulder disability. The Veteran timely appealed. In October 2007, the Veteran testified during a video conference hearing before the undersigned at the RO. In May 2008, the Board remanded the matters for additional development. In July 2011, the Board requested a medical expert opinion from the Veterans Health Administration (VHA) for purposes of addressing medical questions for an equitable disposition of the appeal. See 38 C.F.R. § 20.901 (2012). This opinion was obtained in September 2011 and has been associated with the claims file. The Veteran was notified of the opinion under cover of an April 2012 letter. While evidence generally submitted by the Veteran or representative in response to § 20.903 notification is referred to the AOJ for review unless the Veteran waives this procedural right, situations where a medical expert opinion is obtained by the Board under the authority of 38 C.F.R. § 20.901 are not subject to initial review by the RO. See 38 C.F.R. § 19.9(c)(1). Specifically, the Board is not required to afford a claimant the opportunity to have a claim readjudicated by the AOJ when the only new evidence of record consists of a newly-obtained VHA opinion. In October 2012, the Board remanded the matters for additional development. The Board is satisfied there was substantial compliance with its remand orders with respect to the issues decided herein. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). Lastly, in addition to reviewing the Veteran's paper claims file, the Board has surveyed the contents of his Virtual VA file. The issues of entitlement to a total disability rating based on individual unemployability (TDIU); higher ratings for peripheral neuropathy of the lower extremities, for a left shoulder disability, for hemorrhoids, and for sinusitis; and service connection for peripheral neuropathy of the upper extremities, for herniated disc of the thoracic spine, for left pelvic region stenosis, for hypogonadism, and for tinnitus, have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred again to the AOJ for appropriate action. The issues of service connection for a heart disability, to include mitral valve prolapse and cardiomyopathy; for lumbar spine disabilities; for cervical spine disabilities; and for a right shoulder disability, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. The evidence supports a link between a current vestibular disorder and the peripheral neuropathy resulting from treatment for tuberculosis in service. 2. The Veteran does not have a pulmonary disease or other residuals of treatment for exposure to tuberculosis, other than peripheral neuropathy and a vestibular disorder, that either had their onset in active service or are related to his active service. 3. The Veteran currently does not have residuals of exposure to asbestos that either had their onset in active service or are related to his active service. CONCLUSIONS OF LAW 1. A vestibular disorder was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 2. Residuals of treatment for exposure to tuberculosis, other than peripheral neuropathy and a vestibular disorder, were not incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 3. Residuals of exposure to asbestos were not incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist 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 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). VA should notify the Veteran of: (1) the evidence that is needed to substantiate the claim(s); (2) the evidence, if any, to be obtained by VA; and (3) the evidence, if any, to be provided by the claimant. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Notice and Assistance Requirements and Technical Correction, 73 Fed. Reg. 23,353 (Apr. 30, 2008) (codified at 38 C.F.R. Part 3). VA's most recent letter in November 2012, and earlier letters dated in 2002 and 2008, had notified the Veteran of what evidence he was responsible for obtaining, and what evidence VA would undertake to obtain. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA informed him that it would make reasonable efforts to help him get evidence necessary to support his claims, particularly, medical records, if he gave VA enough information about such records so that VA could request them from the person or agency that had them. In the June 2008 and November 2012 letters, VA's Appeals Management Center (AMC) specifically notified the Veteran of the process by which initial disability ratings and effective dates are established. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Defects as to the timeliness of the statutory and regulatory notice are rendered moot because each the Veteran's claims decided on appeal has been fully developed and re-adjudicated by an agency of original jurisdiction after notice was provided. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran's representative specifically waived RO or AMC consideration of any additional evidence submitted following issuance of the April 2013 supplemental statement of the case (SSOC); hence, no re-adjudication followed. There is no indication that any additional action is needed to comply with the duty to assist the Veteran. The RO or AMC has obtained copies of the service treatment records and outpatient treatment records, and has arranged for VA examinations in connection with the claims decided on appeal, reports of which are of record and appear adequate. The opinions expressed therein are predicated on a substantial review of the record and consideration of the Veteran's complaints and symptoms. The Veteran has not identified, and the record does not otherwise indicate, any existing pertinent evidence that has not been obtained. In Bryant v. Shinseki, 23 Vet App 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that the Veterans Law Judge who chairs a Board hearing fulfill two duties to comply with 38 C.F.R. § 3.103(c)(2). These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. Here, during the hearing, the Veterans Law Judge identified the issues and sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked, or was outstanding that might substantiate the claims. The case was thereafter remanded for additional development including examinations. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2); and no prejudice has been identified in the conduct of the Board hearing. Given these facts, it appears that all available records have been obtained. There is no further assistance that would be reasonably likely to assist the Veteran in substantiating the claims. 38 U.S.C.A. § 5103A(a)(2). II. Service Connection Service connection is awarded for disability that is the result of a disease or injury in active service. 38 U.S.C.A. §§ 1110, 1131. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). For the showing of chronic disease, there must be a combination of sufficient manifestations to identify the disease entity and sufficient observation at the time, as distinguished from isolated findings or a diagnosis including the word "chronic". 38 C.F.R. § 3.303 (2012). When assessing the probative value of a medical opinion, the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). A medical opinion that contains only data and conclusions is not entitled to any weight. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In some cases, lay evidence will also be competent and credible on the issues of diagnosis and etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009) (non-precedential). Specifically, lay evidence may be competent and sufficient to establish a diagnosis where (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau, 492 F.3d at 1377; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). A layperson is competent to identify a medical condition where the condition may be diagnosed by its unique and readily identifiable features. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994); Charles v. Principi, 16 Vet. App 370, 374 (2002). Lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time. 38 U.S.C.A. § 1111. Here, the Veteran contends that each of the disabilities below had its onset during active service. A. Vestibular Disorder The Veteran contends that he suffers from peripheral vestibular disorder that had its onset in service, or alternatively, is secondary to a service-connected disability. 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) (2006). 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) (2006); Allen v. Brown, 7 Vet. App. 439 (1995). Service connection may also be granted for a disability that is proximately due to or the result of an established service-connected disability. 38 C.F.R. § 3.310 (2012). This includes disability made chronically worse by service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). The Board notes that there was an amendment to the provisions of 38 C.F.R. § 3.310. See 71 Fed. Reg. 52744 - 47 (Sept. 7, 2006). The amendment sets a standard by which a claim based on aggravation of a non-service-connected disability by a service-connected one is judged. Although VA has indicated that the purpose of the regulation was merely to apply the Court's ruling in Allen, it was made clear in the comments to the regulation that the changes were intended to place a burden on the claimant to establish a pre-aggravation baseline level of disability for the nonservice-connected disability before an award of service connection based on aggravation may be made. This had not been VA's practice, which suggests the possibility that the recent change amounts to a substantive change in the regulation. For this reason, and because the Veteran's claim was pending before the regulatory change was made, the Board will consider the version of 38 C.F.R. § 3.310 in effect before the change, which is more favorable to the claimant. Any disability which is proximately due to, or results from, another disease or injury for which service connection has been granted, shall be considered a part of the original condition. 38 C.F.R. § 3.310(a) (2012). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service-connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(b) (2012); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Service treatment records contain multiple complaints of dizziness, made generally in concert with complaints involving palpitations. Post-service records show that the Veteran experienced light headedness and flushing of the face in April 1994. He presented to the emergency room, and reported that he had gone to work and had recurrence of symptoms several times. The assessment then was likely a hypoglycemic reaction. Records show that the Veteran was referred for a neurological evaluation; and was briefly placed on seizure control medications, which were stopped without confirmed diagnosis of a seizure disorder. A June 1994 electronystagmography was reported as normal. The Veteran was seen for a near syncope episode in August 1998; however, the narrative summary from that time is unreadable. Subsequently, the Veteran was treated by Dr. Weiss, who considered the Veteran as having a vasovagal problem. The Veteran reportedly had severe vertigo with left tinnitus. MRI scans taken of the brain in September 1998 were interpreted as normal. The Veteran's vertigo was noted to be not as severe in October 1998, and he was prescribed medication. The Veteran continued to complain of vertigo. In February 2000, the Veteran reported daily episodes of vertigo. In May 2000, the Veteran reported that his vertigo would come and go, and that he had not had an episode since he started taking the prescribed medication. Further testing in November 2000 revealed no nystagmus. Records show occasional complaints of vertigo through January 2007. Pursuant to the Board's May 2008 remand, the Veteran underwent a VA audiological examination in August 2008 for purposes of determining the nature and etiology of his complaints of vertigo. The Veteran at the time denied any true complaints of vertigo. He reported experiencing balance problems for approximately 13 years, and described the balance problems as episodic and lasting a few days. While he reportedly had been treated for dizziness, the symptoms have not resolved. The May 2008 examiner diagnosed tinnitus, as well as a history of peripheral neuropathy and thoracic spine problems, which the examiner opined may be causing the Veteran's reported dizziness. Thereafter, on VA audiological examination in April 2010, following an examination of the Veteran, and with consideration of the Veteran's complaints of vertigo, the examiner opined that there was no "strong" evidence of peripheral vestibulopathy from electronystagmography testing. The Board finds this evidence suggestive that a vestibular disorder may be present, although a definitive diagnosis was not rendered. Importantly, other medical records during the period covered by this claim show evidence of vertigo. Ultimately, noncommittal opinions amount to "nonevidence," neither for nor against the claim, because service connection may not be based on speculation or remote possibility. See generally Bloom v. West, 12 Vet. App. 185 (1999) (a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). See also 38 C.F.R. § 3.102 (when considering application of the benefit-of-the-doubt doctrine, reasonable doubt is one within the range of probability, as distinguished from pure speculation or remote possibility). The Board finds the Veteran's lay statements concerning balance problems are not only competent, but also are credible, to show balance problems as episodic in service. His lay statements, therefore, have probative value. See Rucker v. Brown, 10 Vet. App. 67 (1997) and Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). Questions remain, however, whether a current vestibular disorder is related to these episodic balance problems in service, or is secondary to a service-connected disability. The Court has admonished the Board for relying on medical opinions that were unable to establish this required linkage, without resorting to mere speculation, as cause for denying the Veteran's claim. See Jones v. Shinseki, 23 Vet. App. 382 (2010). In Jones, the Court noted it was unclear whether the examiners were unable to provide this requested definitive medical comment on etiology because they actually were unable to since the limits of medical knowledge had been exhausted; or, instead, for example, needed further information to assist in making this determination (e.g., additional records and/or diagnostic studies) or other procurable and assembled data. Id. Pursuant to the Board's October 2012 remand, the Veteran underwent a VA examination in January 2013. The January 2013 examiner reviewed the Veteran's claims file and his medical history. The Veteran described his dizziness as more of an imbalance, especially with eyes closed or darkness. He also reported a history of peripheral neuropathy in both feet, which possibly was related to treatment for a converted positive tuberculosis test in active service. Examination in January 2013 revealed an abnormal Rombert test, which was positive for unsteadiness. Diagnostic testing was conducted, and an electronystagmography could not rule out a central pathology for a vestibular disorder. Following examination, the January 2013 examiner opined that it is more likely than not that episodes of loss balance are related to the service-connected peripheral neuropathy. The January 2013 examiner noted the Veteran's history as supportive of the opinion, and that the Veteran's balance disorder was not likely aggravated by his service-connected anxiety disorder or sinusitis. Given the nature of the disability, the Veteran's lay statements, and post-service treatment records reflecting a likely vestibular disorder, and the January 2013 opinion, the Board finds that the Veteran's vestibular disorder is the result of disease or injury incurred in service. See Hodges v. West, 13 Vet. App. 287, as amended (2000). Accordingly, service connection is warranted for a vestibular disorder. In reaching this decision, the Board has extended the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107. B. Residuals of Treatment for Exposure to Tuberculosis (Other Than Peripheral Neuropathy and a Vestibular Disorder) Service treatment records document the Veteran's exposure to tuberculosis in December 1975, and that he underwent treatment with a year-long regimen of Isoniazid therapy. He underwent regular monitoring of the effects of the drug on his liver by means of testing his serum glutamic oxaloacetic transaminase (SGOT) level. No adverse effects over the course of treatment were noted. Since then, the Veteran contends that he currently suffers from residuals of treatment for exposure to tuberculosis. Records show that he was diagnosed with peripheral neuropathy in February 2003; and in April 2004 and in September 2005, the Veteran's treating physician opined that the peripheral neuropathy was linked to the in-service treatment of Isoniazid therapy. A VA examiner opined that the Veteran's peripheral neuropathy was caused by treatment received in service for tuberculosis. In a July 2010 rating decision, the RO or AMC granted service connection for peripheral neuropathy of the lower extremities. Subsequently, service connection was also awarded for neuropathy of both elbows and for bilateral carpal tunnel syndrome. Pursuant to the Board's October 2012 remand, the Veteran underwent a VA examination in December 2012. The December 2012 examiner reviewed the Veteran's claims file and his medical history. The Veteran reported having a positive purified protein derivative (of tuberculin) in 1974 at Wake Island, while looking after Vietnamese refugees. He reported being treated for one year with Isoniazid therapy. The Veteran denied having any respiratory problems, other than occasional bronchitis; and he took medications for allergies. Chest X-rays revealed no acute cardiac or pulmonary abnormality. Following examination, the December 2012 examiner found no respiratory conditions; the Veteran's lungs were clear to auscultation bilaterally. No significant residuals of treatment for exposure to tuberculosis were found. While the Veteran contends he has current residuals of treatment for exposure to tuberculosis, and while he has a medical background in pharmacology, he is not shown to have the medical expertise to diagnose or determine the etiology of any pulmonary disease. Again, this is not something that would be readily apparent to a lay person. Physicians must rely on examination, medical history, and special diagnostic testing to render a diagnosis and determine etiology. As noted above, the Board finds credible, competent and probative the Veteran's reports of experiencing episodes of dizziness and imbalance in service. However, the VA examiner in December 2012 found no significant residuals of treatment for exposure to tuberculosis. In this regard, the December 2012 examiner's opinion is highly probative evidence against finding a nexus between any residuals and active service, other than peripheral neuropathy and a vestibular disorder. The Board finds the December 2012 examiner's opinion to be probative for resolving the matter on appeal. In this regard, the examiner has the medical knowledge to express a competent opinion; and found no substantial clinical findings of pulmonary disease. The opinion is accurate, and is fully articulated and contains sound reasoning. The evidence does not otherwise show the presence of a pulmonary disability during the pendency of the claim or in close proximity to the claim. In this case, the competent evidence is against a finding that there are additional residuals of treatment for exposure to tuberculosis. A preponderance of the evidence is therefore against a finding that the Veteran currently has residuals of treatment for exposure to tuberculosis other than peripheral neuropathy and a vestibular disorder. The reasonable doubt doctrine is not for application. Thus, service connection for residuals of treatment for exposure to tuberculosis, other than peripheral neuropathy and a vestibular disorder, is not warranted. See 38 U.S.C.A. § 5107(b) (West 2002). C. Residuals of Exposure to Asbestos Service treatment records reveal that the Veteran was exposed to asbestos during his tour of duty at a medical clinic located at Bolling Air Force Base from 1976 to 1980. Records show that the Veteran had multiple chest X-rays. In November 1964, chest X-rays revealed a calcification in the upper right lobe, which was seen on previous films; and there was a positive finding of histoplasmosis. In January 1969, X-rays revealed calcifications and suggested remote granulomatous disease. X-rays taken in December 1975 revealed healed granulomatous calcifications of no clinical significance. Chest X-rays taken at the time of the Veteran's retirement examination in May 1990 also noted past granulomatous disease; and findings of a short stranding density in the left lower lung field, which had not been present on previous X-ray and probably represented post-inflammatory scarring, though the etiology was uncertain. No active disease was found. Pulmonary function tests taken in service in December 1981, August 1983, and in September 1988 also revealed no specific pulmonary disorder. Post-service treatment records show treatment for bronchitis on several occasions. Pursuant to the May 2008 Board remand, the Veteran underwent a VA respiratory examination. The examiner noted exposure to asbestos in service between 1976 and 1980, along with a history of chronic bronchitis and tobacco use until 1995. The examiner noted that there was no evidence of asbestosis either on chest X-rays or on pulmonary function testing. The examiner opined that one could not resolve whether the Veteran suffered from an asbestos-related disease without resorting to speculation. In this regard, the examiner noted that chest X-rays failed to reveal asbestosis; however, there was small airway disease on pulmonary function testing that also could be found with other conditions and was not specific to asbestosis. As noted above, the Court has admonished the Board for relying on medical opinions that were unable to establish this required linkage, without resorting to mere speculation, as cause for denying the Veteran's claim. See Jones v. Shinseki, 23 Vet. App. 382 (2010). Pursuant to the Board's October 2012 remand, the Veteran underwent a VA examination in December 2012. The December 2012 examiner reviewed the Veteran's claims file and his medical history. The Veteran reported being exposed to asbestos in active service. He denied having a chronic cough, epistaxis, hemoptysis, or chest pains. He reported a 30-pack-year history of tobacco use, and that he quit several years ago. As noted above, chest X-rays revealed no acute cardiac or pulmonary abnormality. No respiratory conditions were found on examination. The Veteran's lungs were clear to auscultation bilaterally. Pulmonary function testing was normal. No asbestos-related disease was found. The Veteran is competent and credible to report current respiratory symptoms. While the Veteran has a medical background, he is not shown to have the medical expertise to diagnose or determine the etiology of any current lung disease. Again, this is not something that would be readily apparent to a lay person. Physicians must rely on examination, medical history, and special diagnostic testing to render a diagnosis and determine etiology. While the Veteran might have been at risk for asbestosis or other residuals of exposure in service, neither asbestosis or any residuals have been identified. In fact, the Veteran acknowledged in February 2013 that a baseline was established in or about 1981 to rule out active asbestosis associated with the exposure; and that, if needed, he will reopen his claim in the future. Under these circumstances, the Board finds the December 2012 examiner's opinion to be probative for resolving the matter on appeal. Again, the examiner has the medical knowledge to express a competent opinion; and found no substantial clinical findings of asbestosis or other residuals, which is consistent with results of pulmonary function testing. The opinion is accurate, and is fully articulated and contains sound reasoning. In this case, there is no competent evidence of current asbestosis or pulmonary disease, and certainly none that can be linked to service. A preponderance of the evidence is against a finding that the Veteran has residuals of exposure to asbestos that either had their onset during service or are related to his active service. The reasonable doubt doctrine is not for application. Thus, service connection for residuals of exposure to asbestos is not warranted. See 38 U.S.C.A. § 5107(b) (West 2002). ORDER Service connection for a vestibular disorder is granted. Service connection for residuals of treatment for exposure to tuberculosis, other than peripheral neuropathy and a vestibular disorder, is denied. Service connection for residuals of exposure to asbestos is denied. REMAND The Board notes that service connection has been established for depression, based on longstanding symptoms of depression and anxiety effective June 12, 2002. A VA examiner in December 2012 noted that it was likely that the Veteran's palpitations are from anxiety. Under these circumstances, the Board finds that an addendum opinion is needed to determine whether the Veteran has current symptoms of heart disability, however diagnosed, that either had their onset during service or are related to his active service, or are secondary to the service-connected depression. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)(4) (2012). Lumbar Spine, Cervical Spine, and Right Shoulder Disabilities The Veteran contends that disabilities of his lumbar spine, cervical spine, and right shoulder had their onset in active service. In September 2005, the Veteran's treating physician, Dr. Weiss, opined that the Veteran's lumbar, neck and right shoulder disabilities were attributed to various incidents in active service. Service treatment records show that the Veteran complained of low back pain in December 1980, and include an assessment of acute disc disease. In September 1983, he complained of low back and back spasms after shoveling sand. Diagnosis at the time was low back strain. In May 1985, the Veteran experienced pain in the lumbar region after doing some heavy lifting; and was treated for muscular back strain. A history of low back pain from 1981 was noted at the time of the Veteran's retirement examination in May 1990. X-rays taken of the lumbosacral spine in May 1996 revealed mild degenerative changes of the lower lumbar spine by way of tiny anterior marginal osteophytes at L4-L5. MRI scans conducted in April 1997 revealed a herniated nucleus pulposus at L5-S1, with degenerative disc disease at the same level. With regards to the Veteran's mild arthritic changes of the lumbar spine, a VA examiner in March 2009 opined that it was probably less likely than not that the Veteran's low back pain was due to any in-service injury, as opposed to a condition that gradually developed over time. No rationale for the opinion was provided. In February 2013, the Veteran explained that his duties and responsibilities in active service were far more complicated and strenuous than reflected in the September 2011 expert opinion. The Veteran explained that his unit would deploy and establish a working surgical hospital at times, and that he was solely responsible for all aspects of pharmacy operations-including physical control of narcotics during deployment, which were in a locked storage container and required heavy lifting. His duties also required "setting up" common working areas, sleeping areas, dining areas, and areas for maintaining patients or wards. The Veteran explained that he helped in constructing tents, which were bulky and weighed in excess of 200 pounds. He also reported being the only pharmacy person available on a two-month deployment to Wake Island, where he filled an average of 500 prescriptions daily and typed on a manual typewriter, working seven days a week for ten to twelve hours each day. Likewise, the Veteran offered competent statements of first-hand knowledge that he sustained minor injuries to his cervical spine in active service, although there were no documented complaints. In February 2013, the Veteran recalled several injuries that occurred over the years in active service while participating in intramural sports. For example, he noted jammed fingers, twisted or sprained ankles, sore or aching throwing arm, wounds from being spiked by someone sliding into base, being undercut when driving for lay-ups, twisting or hyperextending elbows or knees, blisters on his feet, blisters on his fingers, occasional wrist injuries, blisters on his hands, and injuries when stepping off or landing wrong and banging an elbow. With regard to his right shoulder disability, the Veteran complained of longstanding problems with the right shoulder that dated back several years. X-rays taken in September 2001 revealed moderate degenerative joint changes of the glenohumeral joint and the acromioclavicular joint. Given the Veteran's strenuous activities in active service as reported, the Board finds that further medical clarification is required. Specifically, the March 2009 examiner suggested that it was very likely that the Veteran's degenerative changes of the lumbar spine and right shoulder occurred over time from wear and tear, although the examiner did not elaborate as to whether the changes occurred in-service or post-service. The March 2009 examiner also suggested that the Veteran's cervical spine disability was caused by gradual degeneration over time and not likely due to any specific in-service injury. The Board notes that the Veteran served for nearly 28 years on active service, and that his history of low back pain during active service is well documented. Under these circumstances, the Board finds that an addendum opinion is needed to determine whether the Veteran's current disabilities of the lumbar spine, cervical spine, and right shoulder either had their onset during service or are related to his active service-specifically, to include wear and tear from strenuous in-service activities over many years. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)(4) (2012). Accordingly, the case is REMANDED for the following action: 1. The April 2013 VA addendum report should be returned to the physician (or another clinician) for an addendum expressing an opinion as to whether it is at least as likely as not (50 percent probability or more) that heart symptoms manifested during the course of this claim, however diagnosed, are the result of disease or injury incurred in active service-specifically, to include episodes of premature ventricular contractions and palpitations in active service, as noted in service treatment records, and the Veteran's account of intermittent palpitations since then. The clinician should also determine whether it is at least as likely as not (50 percent probability or more) that the Veteran's current heart disorder, whether diagnosed as mitral valve prolapse, cardiomyopathy, tricuspid regurgitation, etc., is due to service-connected depression. The clinician should also determine whether it is at least as likely as not (50 percent probability or more) that the Veteran's current heart disorder, whether diagnosed as mitral valve prolapse, cardiomyopathy, tricuspid regurgitation, etc., is aggravated (i.e., increased in severity) beyond the natural progress by service-connected depression. The clinician's attention is directed to the December 2012 and April 2013 reports indicating that palpitations and anxiety are related. The clinician is asked to explain the reasons behind any opinions offered. The clinician is also reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the physician's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. The Veteran's claims file must be provided to the clinician designated, and the addendum report should note review of the file. 2. The December 2012 VA examination report should be returned to the examiner (or another clinician) for an addendum expressing an opinion as to whether it is at least as likely as not (50 percent probability or more) that disabilities of the lumbar spine, cervical spine, and the right shoulder are related to active service-specifically, to include wear and tear from strenuous in-service activities over many years, as reported by the Veteran, and the Veteran's account of intermittent pain since then. The clinician is asked to explain the reasons behind any opinions offered. The clinician is also reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the physician's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. The Veteran's claims file must be provided to the clinician designated, and the addendum report should note review of the file. 3. After ensuring that the requested actions are completed, the RO or AMC should take any other development action deemed warranted and re-adjudicate the claims on appeal. If the benefits sought are not fully granted, the RO or AMC must furnish a SSOC, before the claims file is returned to the Board, if otherwise in order. The Veteran 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). These claims 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). ______________________________________________ S. S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs