Citation Nr: 1325802 Decision Date: 08/15/13 Archive Date: 08/26/13 DOCKET NO. 09-06 990A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depression, and insomnia. 2. Entitlement to service connection for type II diabetes mellitus, to include as due to herbicide exposure. 3. Entitlement to service connection for a heart disorder, to include ischemic heart disease and hypertension, to include as due to herbicide exposure. 4. Entitlement to service connection for peripheral neuropathy of the right upper extremity, to include as secondary to type II diabetes mellitus. 5. Entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as secondary to type II diabetes mellitus. 6. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to type II diabetes mellitus. 7. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to type II diabetes mellitus. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD K. Osegueda, Associate Counsel INTRODUCTION The Veteran had active service from July 1971 to July 1973. He had confirmed service aboard the USS Kilauea (AE-26), which operated at various times, from May 1972 to June 1972, in the waters off the shore of the Republic of Vietnam (Vietnam). This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The Board notes that the psychiatric claim on appeal has been developed as a claim for PTSD. The Court of Appeals for Veterans Claims has held that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). As such, the claim has been recharacterized to include any psychiatric disorder. In April 2013, the Veteran testified at a hearing held at the RO before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the record. In addition to the paper claims file, there is a Virtual VA paperless file associated with the Veteran's case. A review of the documents in the paperless claims file reveals the hearing transcript and VA treatment records that they are relevant to the issues on appeal. The RO considered those additional treatment records and readjudicated the claims in a December 2012 supplemental statement of the case (SSOC). Thus, there is no prejudice in the Board considering such evidence. The issues of entitlement to service connection for type II diabetes mellitus, a heart disorder, and peripheral neuropathy of the right and left upper and lower extremities, 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 more probative evidence shows that the Veteran does not meet the diagnostic criteria for PTSD. 2. An acquired psychiatric disorder other than PTSD did not manifest in service or for many years thereafter and has not been shown to be causally or etiologically related to his military service. CONCLUSION OF LAW An acquired psychiatric disorder, to include PTSD, depression, and insomnia, was not incurred in service, and a psychosis may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1103, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.301, 3.303, 3.304(f), 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Upon receipt of a substantially complete application for benefits, VA must notify the claimant of what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and, (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In this case, the RO provided the Veteran with notification letters in December 2006 and March 2007, prior to the initial decision on the claim in August 2008. Therefore, the timing requirement of the notice as set forth in Pelegrini has been met and to decide the appeal would not be prejudicial to the claimant. Moreover, the content of the December 2006 and March 2007 letters satisfied the notice requirements. In this regard, the letter informed the Veteran of the information and evidence needed to substantiate his claim for service connection and notified him of the division of responsibilities in obtaining such evidence. The letter also explained how a disability rating is determined for a service-connected disorder and the basis for determining an effective date upon the grant of any benefit sought, in compliance with Dingess, 19 Vet. App. at 490-491. In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records as well as all identified and available post-service medical records are in the claims file and were reviewed by both the RO and the Board in connection with the claim. The Veteran has not identified any other outstanding records that are pertinent to the issue being decided herein. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the Veteran was afforded a VA examination in August 2011. There has been no allegation that the examination was inadequate. Moreover, the Board finds that the August 2011 VA medical opinion obtained in this case is adequate, as it is predicated on a full reading of the available service treatment records as well as the post-service medical records contained in the Veteran's claims file. It considers all of the pertinent evidence of record and provides a complete rationale for the opinions stated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). Additionally, as previously noted, the Veteran was provided the opportunity to testify at a hearing before the undersigned Veterans Law Judge in April 2013. The undersigned Veterans Law Judge clearly set forth the issue to be discussed, and the hearing focused on the elements necessary to substantiate the claim. Questions were asked regarding the Veteran's symptoms in service and the progression of the disorder since service. The undersigned Veterans Law Judge also inquired as to whether the Veteran was receiving any current treatment in order to determine whether there was any outstanding evidence and asked whether the Veteran had spoken to any doctors about the cause of his current disorder in order to determine whether there may be a medical opinion that could be obtained from a treatment provider. For these reasons, the Board finds that VA fully complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). VA has further assisted the Veteran and his representative throughout the course of this appeal by providing them with a Statement of the Case (SOC) and numerous Supplemental Statements of the Case (SSOC), which informed them of the laws and regulations relevant to the Veteran's claim. The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide the particular claim on appeal. He has been given ample opportunity to present evidence and argument in support of his claim. For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. Law and Analysis Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish entitlement to service connection for a disability, the Veteran must show: (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, 1166-67 (Fed. Cir. 2004). Service connection for PTSD requires medical evidence diagnosing the condition; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). Service connection for certain diseases, such as psychoses, may be also be established on a presumptive basis by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for an acquired psychiatric disorder. During a December 2006 VA mental health consultation, the Veteran indicated that he served aboard a Navy aircraft carrier from 1972 to 1973. He denied involvement in combat, and he did not identify any stressors related to his service. Therefore, the examiner concluded that the Veteran did not meet the criteria for a diagnosis of PTSD. She noted that he did endorse some symptoms of depression, but he did not meet the criteria for major depression. In a December 2006 stressor statement, the Veteran described three incidents in support of his claim for service connection for PTSD. First, he stated that he was standing next to a member of the crew aboard the USS Kilauea and witnessed the sailor being hit with a pallet of ammunition during a transfer of the cargo to another ship. Second, he reported that, while he was serving as the first gun crew member on the USS Kilauea, he was test firing shells when a shell became locked in the breech and did not fire. He indicated that, according to standard operating procedures, the gun chief removed the shell that did not fire and handed it to him to throw overboard. He stated, "This was a very scary time, (sic) because misfires went off on [the] slightest bobble." Third, he reported that he handled nuclear weapons during transfers to other ships at sea. In a July 2007 VA primary care treatment note, the Veteran reported that he had good relief of his insomnia with Trazodone. A diagnosis of insomnia with sleep apnea was provided. In August 2007, the Veteran submitted a copy of an internet article entitled, "The Vietnam War and PTSD." The author stated, "The majority of Vietnam veterans experienced, witnessed, or were actually involved in death threatening circumstances. Their response involved intense fear, helplessness, or horror all resulting in [PTSD]." In statements submitted in August 2007, the Veteran described the USS Kilauea as a "floating bomb." He reported that he was a member of the deck division. He stated that he loaded pallets of bombs, ammunition, and missiles aboard the ship and unloaded similar cargo off of the ship to other ships off of the coast of Vietnam. He also reported that he was a "shell handler" on the gun mount and was handed misfired shells to throw over the side of the ship. In an August 2007 stressor statement, the Veteran reported that his main job was offloading nuclear weapons from his ship and loading them on to carriers and cruisers in South Vietnam. In October 2007, the Veteran submitted an internet article in which the author reported that many Vietnam and Korean War veterans are becoming aware that they have PTSD because they recognize their symptoms in those returning from Iraq with diagnoses of PTSD. A December 2007 VA primary care treatment note shows the Veteran had a positive PTSD screen and a negative depression screen. A July 2009 VA primary care treatment note indicates the Veteran had a positive PTSD screen and a negative depression screen. During an August 2010 VA mental health consultation, the Veteran denied any disciplinary actions during service, but he "rather proudly reported[] being thrown into jail in every port his ship went." He reported that he helped put a nuclear submarine into dry dock for repairs during service. He described being handed a shell that did not fire to throw overboard and having to man a gun mount for long periods of time when his ship was operating off of the coast of northern Vietnam. He also stated that it was traumatic to work with other sailors who had criminal histories. During the August 2010 VA mental health consultation, the Veteran reported that he could "go a week without drinking" followed by three or four drinks for several nights. He indicated that he drank a case of beer over the past weekend, and three weeks ago, he drank a 12 pack of beer over a period of two days. The diagnosis was alcohol abuse. A March 2011 VA treatment note included Minnesota Multiphasic Personality Inventory-2nd Edition (MMPI-2) test results "similar to persons usually diagnosed as having a somatoform disorder, anxiety disorder, or depressive disorder." In a March 2011 VA mental health note, the examining clinical psychologist noted that the Veteran did not meet the Fourth Edition of the American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnostic criteria for a PTSD diagnosis. He reported that the MMPI showed a moderate level of depression, but he was "concerned" that the Veteran's alcohol consumption could be a factor contributing to his depressive symptoms. The Veteran reported he was sleeping seven hours per night and woke two to three times per night. The examiner noted that he was "vague as to what might cause the awakenings." The Veteran denied having nightmares. The examiner noted that VA treatment notes reflect the Veteran was prescribed Trazodone as a sleep aid. No Axis I diagnosis was provided. During an August 2011 VA examination, the Veteran reported that he was treated for insomnia by his primary care physician and took Trazodone for his symptoms. He indicated that he was treated by a VA mental health practitioner twice in 2010, but he denied any current mental health treatment. He endorsed the following symptoms: depressed mood, chronic sleep impairment, and mild memory loss. The examiner reported that the Veteran did not have a diagnosis of PTSD that conformed to the DSM-IV criteria. She provided an Axis I diagnosis of insomnia and noted that his symptoms did not meet the diagnostic criteria for a current diagnosis of PTSD. She reported that he was not currently receiving treatment for PTSD, and testing conducted at the VA outpatient clinic was not consistent with a diagnosis of PTSD. Therefore, she opined that it was less likely as not that his current symptoms were the result of trauma experienced while serving off shore in the Navy. She also opined that it was not likely that his current symptoms of insomnia were related to any incident that occurred during service. During the April 2013 hearing, the Veteran testified that he was a "nervous wreck" in service when he handled nuclear weapons to transfer them from ship to ship and when he was posted as a guard in front of the "nuke hole" while in port. He stated that it was "mind-boggling" to think about handling weapons that would "kill a whole bunch of people." He also testified that he was constantly fearful that his ship was a potential target during the war because it was an ammunition ship. He denied seeking any treatment for his claimed nervous condition in service. He testified that he had symptoms and issues "almost immediately" following service. He indicated that he had difficulty transitioning from "working with weapons to nothing." He reported that he did not seek treatment for his symptoms for "a long time." He indicated that he finally sought treatment not "terribly long ago" from a VA physician. He stated that he was prescribed Trazodone for insomnia. As noted above, service connection for PTSD requires medical evidence diagnosing the condition; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). In this case, the medical evidence of record does not show that he has actually been diagnosed with PTSD. He did have a positive PTSD screen in December 2007 and July 2009, but upon further evaluation, it was determined that the Veteran did not have PTSD in December 2006, March 2011, and August 2011. In each instance, the examiners determined that the Veteran's symptoms did not meet the diagnostic criteria for a current diagnosis of PTSD. In fact, both the March 2011 psychologist and the August 2011 VA examiner specifically indicated that he did not meet the criteria under the DSM-IV, which is required under the regulations. See 38 C.F.R. §§ 3.304(f), 4.125. The Veteran has not identified any outstanding records that are pertinent to the claim of service connection for an acquired psychiatric disorder, to specifically include treatment for PTSD. While the Veteran is competent to provide testimony or statements relating to symptoms or facts of events that he has observed and is within the realm of his personal knowledge, he is not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). The record does not show, nor does the Veteran contend, that he has specialized education, training, or experience that would qualify him to render a diagnosis or render a medical opinion on this matter. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the issue in this case is outside the realm of common knowledge of a lay person. In other words, he is not competent to state that he has one psychiatric diagnosis versus another one. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Moreover, the regulations specifically require that diagnoses of PTSD be rendered in accordance with the diagnostic criteria for the condition set forth in the DSM-IV. See 38 C.F.R. § 4.125 (noting that VA has adopted the nomenclature of the DSM-IV). Thus, the Veteran's own statements are not sufficient to establish a diagnosis of PTSD. Based on the foregoing, the Board finds that the preponderance of the competent and probative evidence shows that the Veteran does not have a current diagnosis of PTSD. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1110, 1131; see Degmetich v. Brown, 104 F. 3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Accordingly, where, as here, competent medical evidence indicates that the Veteran does not have the disability for which service connection is sought, there can be no valid claim for service connection for the disability. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Thus, there is no basis upon which to award service connection, and discussion of the remaining criteria of 38 C.F.R. § 3.304(f) is unnecessary. Nevertheless, as discussed above, the Court has held that claims for service connection for PTSD includes claims for service connection for any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). With respect to the Veteran's depressive symptoms, the Board finds that, as with his claimed PTSD, the Veteran does not have a current diagnosis of depression. In fact, the Veteran had negative depression screens during VA treatment in December 2007 and July 2009. The Board acknowledges that the Veteran did endorse some depressive symptoms during a December 2006 VA mental health consultation; however, the examiner opined that he did not meet the criteria for major depression. Likewise, a March 2011 VA treatment note included MMPI-2 test results that demonstrated symptoms "similar to persons usually diagnosed as having a somatoform disorder, anxiety disorder, or depressive disorder." However, in a March 2011 VA mental health note, the examining clinical psychologist noted that, although the MMPI showed a moderate level of depression, he was "concerned" that the Veteran's alcohol consumption could be a factor contributing to his depressive symptoms. He provided no Axis I diagnosis. Thus, despite some symptoms suggestive of depression, there has been no actual diagnosis rendered in this case. The evidence of record does show that the Veteran does have a current Axis I diagnosis of insomnia. However, his service treatment records are negative for any complaints, treatment, or diagnosis of insomnia. The Veteran did not seek treatment for and was not diagnosed with insomnia until many years after service. Instead, the first recorded evidence of treatment for insomnia was documented in a July 2007 VA treatment note. Indeed, the Veteran testified that he had not sought treatment for his insomnia symptoms until recently. With regard to the years-long evidentiary gap in this case between active service and the earliest documented manifestations of insomnia, the Board notes that a prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board must consider all the evidence including the availability of medical records, the nature and course of the disease or disability, the amount of time that elapsed since military service, and any other relevant facts in considering a claim for service connection. Id.; cf. Dambach v. Gober, 223 F.3d 1376, 1380-81 (Fed. Cir. 2000) (holding that the absence of medical records during combat conditions does not establish absence of disability and thus suggesting that the absence of medical evidence may establish the absence of disability in other circumstances). Thus, when appropriate, the Board may consider the absence of evidence when engaging in a fact finding role. See Jordan v. Principi, 17 Vet. App. 261 (2003) (Steinberg, J., writing separately) (noting that the absence of evidence may be considered as one factor in rebutting the aggravation part of the section 1111 presumption of soundness). In addition to the lack of evidence showing that insomnia manifested during active duty service or within close proximity thereto, the evidence of record does not link any current diagnosis to the Veteran's military service. In fact, the August 2011 VA examiner opined that it was not likely that his current symptoms of insomnia were related to any incident that occurred during service. The Board also acknowledges that the Veteran submitted various internet articles to support his claim. "Competent medical evidence" may mean statements conveying sound medical principles found in medical treatises. It would also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. See 38 C.F.R. § 3.159(a)(1). However, treatise evidence alone is usually "too general and inconclusive" to establish a medical nexus. Sacks v. West, 11 Vet. App. 314, 317 (1998). A medical article or treatise can provide important support when combined with an opinion of a medical professional if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least a plausible causality based upon subjective facts rather than unsubstantiated lay opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999). In this case, however, the articles are general in nature, and no medical professional has related the information contained therein to the Veteran. Therefore, the Board concludes that such evidence is entitled to little probative weight. Accordingly, the claim for service connection for an acquired psychiatric disorder, to include PTSD, depression, and insomnia, must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of- the-doubt doctrine. However, on these facts, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depression, and insomnia, is denied. REMAND The Board's review of the claims file reveals that further RO/AMC action concerning the issues on appeal is warranted. The Veteran contends that his current type II diabetes mellitus and heart disorder, to include ischemic heart disease and hypertension, were caused by exposure to herbicide agents during service in Guam and Vietnam. The Veteran's enlisted performance record indicates that he served at the Naval Ship Repair Facility in Guam from September 1971 to September 1972. The record also shows that he served on the USS Kilauea from September 1972 to July 1973. During the April 2013 Board hearing, the Veteran reported that he served for approximately nine months in Guam working on three dry docks. He testified that he was unaware that herbicides were being used or staged at that location. See Board hearing transcript, pp. 3-4. However, at the hearing, the Veteran and his representative submitted various internet articles that detailed the use of herbicide agents and the contamination of the water supply in certain locations in Guam. The Veteran also testified that, after his service in Guam, he received orders to report to the USS Kilauea. He stated that, prior to boarding the ship, he was flown to the Philippines to wait for the ship to arrive in port. During his seven day stay, he lived on the USS Benewah, a barracks barge, in Subic Bay in the Philippines. He reported that the barge was tied up and stayed stationary in port at Subic Bay. See Board hearing transcript, pp. 4-7. Prior to the hearing, the Veteran submitted a statement in March 2012, stating that he reported aboard the USS Benewah while waiting on the USS Kilauea to arrive in port. He also submitted a copy of an alphabetized list of ships exposed to Agent Orange from the internet. The USS Benewah (APB-35) was among the ships listed as a ship operating primarily or exclusively on Vietnam's inland waterways. The Veteran further testified that, after reporting aboard the USS Kilauea, the ship operated from Subic Bay to the coast of Vietnam. He reported that the USS Kilauea was an ammunition ship that performed underway replenishments (UNREPS) with various types of ships. He stated that the ship never pulled into port in Vietnam, but he traveled to Vietnam on four separate occasions via helicopter to help load and unload supplies and mail. See Board hearing transcript, p. 8 and July 2011 DRO hearing transcript, pp. 3-4. He indicated that there was no official record that documented his travel to Vietnam because he volunteered for work party details. See Board hearing transcript, pp. 8-10. The Veteran's DD-214 indicates that he served in Vietnam. However, the evidence of record does not show that the Veteran actually "set foot" in Vietnam. See Haas v. Nicholson, 20 Vet. App. 257 (2006), rev'd sub nom. Haas v. Peake, 525 F.3d 1168 (Fed Cir. 2008), cert. denied, 129 S. Ct. 1002 (2009) (holding that VA's requirement that a veteran must have been present within the land borders of Vietnam-must have actually set foot therein-at some point in the course of duty in order to be entitled to a presumption of herbicide exposure constitutes a permissible interpretation of 38 U.S.C.A. § 1116(a)(1) and 38 C.F.R. § 3.307(a)(6)(iii). A February 2011 Personnel Information Exchange System (PIES) response to a request for documentation of the dates of the Veteran's service in Vietnam indicated an inability to determine whether the Veteran served in Vietnam. The response noted that the Veteran served aboard the USS Kilauea which was in the official waters of Vietnam on May 6, 1972, from May 13, 1972 to May 23, 1972, and from May 30, 1972, to June 1972; however, "the record provides no conclusive proof of in-country service." In response to an inquiry by the RO for deck logs from the USS Kilauea dated from February 1973 to March 1973, the National Archives Records Administration reported that the ship was enroute from Subic Bay in the Philippines to the coast of Vietnam at the end of March 1973 and it operated on the coast of Vietnam from April 4, 1973, to April 17, 1973. Additionally, a July 2008 Center for Unit Records and Research (CURR) response indicated that navigation deck logs dated in April 1973 included no points of land as a fix or any geographic reference point, thereby indicating that the ship was "operating well off the coast" of Vietnam. The report also noted that 1972 and 1973 command histories documented various operations to replenish Seventh Fleet ships with ammunition in the northern Gulf of Tonkin off the coast of North Vietnam and Operation Market Time and Naval Gunfire Support units operating in the coastal waters of Vietnam by performing UNREPS and vertical replenishments (VERTREPS). The ship would restock in Subic Bay in the Philippines and make line swing periods into the combat zone. Nevertheless, it does not appear that any development was performed with regards to the Veteran's assertion that he traveled to Vietnam via helicopter on work party details. Despite his testimony that there are no records documenting his participation in the work party details, the RO/AMC should seek any available records pertaining to flights originating from the USS Kilauea to Vietnam. The Veteran should also be afforded VA examinations to determine the nature, extent, and etiology of the claimed disorders. See 38 C.F.R. § 3.159(4); McLendon v. Nicholson, 20 Vet.App. 79 (2006). The Board further notes that a decision on the claim for service connection for diabetes mellitus could change the outcome of the Veteran's claim for service connection for peripheral neuropathy of his extremities. In this regard, the Board observes that the Veteran has contended that the latter disorders are secondary to his diabetes mellitus. As such, the claims are inextricably intertwined. For this reason, the issue of service connection for diabetes mellitus must be resolved prior to resolution of the claims for service connection for peripheral neuropathy. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (the prohibition against the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). Accordingly, a remand is required for the RO/AMC to adjudicate the inextricably intertwined issue. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should request that the Veteran identify the names, addresses, and approximate dates of treatment for any VA and non-VA health care providers who have treated him for his type II diabetes; a heart condition, to include ischemic heart disease; hypertension; and peripheral neuropathy. A specific request should be made for any outstanding private treatment records. After obtaining any necessary authorization from the Veteran, the RO/AMC should attempt to obtain copies of pertinent treatment records identified by the Veteran in response to this request that are not already contained in the claims file. Any negative search result should be noted in the record. A specific request should also be made for all outstanding VA treatment notes dated from November 2012 to present. 2. The RO/AMC should request from the appropriate agency any and all available documentation, including, but not limited to, flight logs, passenger manifests, and operational reports, of any flights from the USS Kilauea (AE-26) to Vietnam in 1973. Any available records must be obtained and associated with the claims file. If the search for such records has negative results, the claims file must be properly documented as to the unavailability of those records. 3. After completing the preceding development, the Veteran should be afforded a VA examination to determine the nature and etiology of any type II diabetes mellitus and peripheral neuropathy that may be present. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and statements. It should be noted that the Veteran is competent to attest to observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner is requested to review the claims file and to identify any current type II diabetes mellitus and peripheral neuropathy. For each diagnosis identified, the examiner should discuss whether it is at least as likely as not that the disorder manifested in service or is otherwise causally or etiologically related to his military service. With respect to the Veteran's claimed peripheral neuropathy, the examiner should comment as to whether it is at least as likely as not that any peripheral neuropathy was caused by or permanently aggravated by his type II diabetes mellitus. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1, copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 4. The Veteran should also be afforded a VA examination to determine the nature and etiology of any heart condition, to include ischemic heart disease and hypertension, that may be present. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and statements. It should be noted that the Veteran is competent to attest to observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner is requested to review the claims file and to identify all current heart disorders, to include ischemic heart disease and hypertension. For each diagnosis identified, the examiner should discuss whether it is at least as likely as not that the disorder manifested in service or is otherwise causally or etiologically related to his military service. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1, copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 5. After completing the above actions, the RO/AMC should conduct any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs. 6. When the development has been completed, the case should be reviewed by the RO/AMC on the basis of additional evidence. If the benefits sought are not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the 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). ______________________________________________ JESSICA J. WILLS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs