Citation Nr: 1326139 Decision Date: 08/16/13 Archive Date: 08/26/13 DOCKET NO. 09-01 760 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for squamous cell carcinoma of the right neck, including as due to herbicide exposure and secondary to a service-connected splenectomy and calcified paratracheal lymph nodes. 2. Entitlement to service connection for a disorder of the salivary glands, to include as secondary to squamous cell carcinoma of the right neck. 3. Entitlement to service connection for tooth loss, to include as secondary to squamous cell carcinoma of the right neck. 4. Entitlement to service connection for bilateral hearing loss, to include as secondary to squamous cell carcinoma of the right neck. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL Appellant and his wife. ATTORNEY FOR THE BOARD M. Riley, Counsel INTRODUCTION The Veteran served on active duty from May 1968 to December 1990. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. Jurisdiction over the claims file is currently held by the RO in New Orleans, Louisiana. In August 2010, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The case was previously before the Board in November 2010 when it was remanded for additional development by the originating agency. It has now returned to the Board for further appellate action. The issue of entitlement to service connection for bilateral hearing loss 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. Squamous cell carcinoma of the right neck was not present in service or until years thereafter, is not etiologically related to any incident of service including exposure to herbicides, and is not caused or aggravated by a service-connected disability. 2. A disorder of the salivary glands, manifested by sicca syndrome, laryngitis, pharyngitis, a loss of the sense of taste and smell, and xerostomia, was not present in service or until years thereafter, is not etiologically related to any incident of service, and is not caused or aggravated by a service-connected disability. 3. The Veteran's missing teeth are not etiologically related to any incident of service and are not caused or aggravated by a service-connected disability; there is no loss of substance of the maxilla or mandible due to trauma or disease. CONCLUSIONS OF LAW 1. Squamous cell carcinoma of the right neck was not incurred in or aggravated by active service and its incurrence or aggravation may not be presumed. 38 U.S.C.A. §§ 1110, 1116, 1131, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. A disorder of the salivary glands was not incurred in or aggravated by active service and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310. 3. Service connection for the Veteran's missing teeth for compensation purposes is precluded by law. 38 U.S.C.A. §§ 1110, 1131, 1712; 38 C.F.R. §§ 3.303, 3.381, 4.150, 17.161. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a 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"-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). See also Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007). When a chronic disease is shown in service sufficient to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Id. When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Id. For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)(holding that the term "chronic disease in 38 C.F.R. § 3.309(b) is limited to a chronic disease listed at 38 C.F.R. § 3.309(a)). Service connection may 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). Additionally, for veteran's who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic diseases, such as malignant tumors, are presumed to have been incurred in service if such manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a), 3.309(a). Service connection is also provided for a disability which is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Squamous Cell Carcinoma The Veteran contends that service connection is warranted for squamous cell carcinoma of the right neck as it was incurred due to herbicide exposure during active duty service. The Veteran testified in August 2010 that his cancer arose in the respiratory system and is therefore entitled to presumptive service connection due to herbicide exposure in accordance with 38 C.F.R. §§ 3.307 and 3.309. The Veteran's testimony also indicates that his cancer could be due to the service-connected residuals of a ruptured spleen with splenectomy and calcified paratracheal lymph nodes or is related to in-service treatment for upper respiratory infections (URIs). The record clearly demonstrates the presence of a current chronic disability. In January 2005, the Veteran was seen at the Alexandria VA Medical Center (VAMC) with complaints of a swollen right submandibular gland. An ears, nose, and throat (ENT) consultation was performed in August 2005, and an enlarged juglo-digiastric lymph node was diagnosed. A fine needle biopsy was performed in September 2005 and indicated poorly differentiated squamous cell carcinoma. The Veteran was examined by an oncologist in October 2005 for carcinoma of an unknown primary site with metastatic disease to the neck. A quadruple endoscopy did not indicate the presence of the cancer's primary location and an October 2005 PET scan showed some uptake in the region of the oropharynx and the base of the tongue. The oncologist recommended that the Veteran begin a course of radio chemotherapy. The Veteran was referred to a private facility for chemotherapy and in October 2005 was examined by a private oncologist. The oncologist characterized the Veteran's condition as poorly differentiated squamous cell carcinoma at the neck with a probable primary site from an oropharyngeal-based lesion shown on PET. The Veteran underwent chemotherapy from November 2005 to January 2006 which successfully treated his cancer. VA and private treatment records show that the Veteran's cancer has been in remission since January 2006. A VA examiner diagnosed the Veteran with squamous cell carcinoma of the head and neck with a most likely primary source of the base of the tongue and pharynx. A current disability is therefore established by the record. With respect to whether the Veteran incurred a service injury, service records are negative for evidence pertaining to oropharyngeal and/or neck cancer. There are no complaints or treatment during service for any neck abnormalities and the Veteran's head, neck, mouth, and throat were normal at the December 1990 retirement examination. The Veteran contends that his oropharyngeal cancer was incurred due to herbicide exposure during active duty service. Although service treatment records do not document any findings indicative of cancer, personnel records confirm the Veteran's presence in Vietnam during active duty service. His exposure to herbicides is therefore presumed and an in-service injury is established. See 38 U.S.C.A. §§ 1116(f), 1154; 38 C.F.R. § 3.309(e); see also Haas v. Peake, 525 F.3d 1168 (2008); VAOPGCPREC 27-97. VA regulations provide for a presumption of service connection for certain disabilities associated with herbicide exposure under 38 C.F.R. §§ 3.307 and 3.309 (2012). The Veteran contends that his squamous cell carcinoma is a respiratory cancer and is therefore entitled to presumptive service connection under 38 C.F.R. §§ 3.307 and 3.309. He testified in August 2010 that a PET scan performed in August 2005 indicated the primary source of his cancer was a lesion at the base of the tongue and his cancer should be characterized as throat cancer associated with the respiratory system. 38 C.F.R. § 3.309 provides that presumptive service connection is warranted for respiratory cancers specified as cancer of the lung, bronchus, larynx, and trachea. The Veteran's cancer was found by his treating physicians and the August 2008 VA examiner to have most likely originated in the pharynx, which is not identified as a respiratory cancer by 38 C.F.R. § 3.309. Additionally, internet medical articles submitted by the Veteran in support of his claim note that the pharynx is considered part of the throat, but ends at the top of the trachea, the highest organ specified by 38 C.F.R. § 3.309 as belonging to the respiratory system. The August 2008 VA examiner also found that the Veteran's cancer definitely did not arise at the level of the vocal cords or lower. The Board has considered the Veteran's statements associating his squamous cell carcinoma with the respiratory system, but as a layperson, he is not competent to render a medical opinion. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Grover v. West, 12 Vet. App. 109, 112 (1999). The weight of the medical evidence clearly establishes that the Veteran's cancer did not originate in or involve the respiratory system. Furthermore, the August 2008 VA examiner noted that the Veteran's cancer was not a sarcoma and service connection on a presumptive basis as a soft tissue sarcoma is also not appropriate. The competent medical evidence therefore establishes that the Veteran's cancer is not subject to presumptive service connection based on herbicide exposure under 38 C.F.R. §§ 3.307 and 3.309. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has determined that a Veteran is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Therefore, while service connection on a presumptive basis is not possible for the Veteran's claimed disability due to herbicide exposure, the Board will determine whether service connection is warranted as directly due to active duty service and exposure to herbicides. Regarding the third element of service connection, a nexus between the Veteran's current disability and the in-service injury, the Board notes that service records do not indicate such a link. No chronic conditions were noted on the December 1990 retirement examination and the service records do not contain any complaints of abnormalities to the neck, pharynx, or tongue. There is also no evidence of a malignant tumor until January 2005, 15 years after service, when the Veteran complained of pain from a right swollen gland in his neck at the Alexandria VAMC. Service connection is therefore not possible for the Veteran's cancer as a chronic disease subject to presumptive service connection under 38 C.F.R. §§ 3.307 and 3.309. The absence of any clinical evidence for years after service weighs the evidence against a finding that squamous cell carcinoma was present in service or in the year immediately after service. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). The weight of the medical evidence is also against a finding of service connection due to service. The record does not contain any competent medical evidence in favor of a link between the Veteran's squamous cell carcinoma and any incident of active service, to include exposure to herbicides or the Veteran's in-service treatment for URIs. The only medical opinions of record, those of August 2008 VA ENT and respiratory examiners, weigh against the claim. After reviewing the complete claims file and physically examining the Veteran, the VA examiners concluded that there was no connection between the Veteran's cancer and his respiratory infections during service. Additionally, the August 2008 ENT examiner noted that pharyngeal squamous cell carcinoma is not associated with herbicide exposure. The August 2008 VA medical opinions were based on an accurate history of the Veteran's condition and were supported with well-reasoned rationales. Hence, they are entitled to significant probative value. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). The weight of the medical evidence is also against service connection on a secondary basis. The Veteran's service-connected disabilities include residuals of a ruptured spleen and splenectomy and calcified paratracheal lymph nodes. There is no competent medical evidence in support of the claim for secondary service connection and the August 2008 VA ENT and respiratory examiners provided medical opinions against the claim. The ENT examiner specifically found that there was no scientific evidence of an association between the service-connected splenectomy and calcified lymph nodes and delayed onset squamous cell carcinoma. Service connection is possible for certain chronic disabilities, such as malignant tumors, under 38 C.F.R. § 3.303(b) based on a continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In this case, the Veteran has not reported a history of continuous symptoms of squamous cell carcinoma since active duty service. He first complained of a swollen right gland in his neck at the VAMC in January 2005 and at that time reported a one month history of the condition. As the Veteran has not reported a continuity of symptoms since service, service connection under 38 C.F.R. § 3.303(b) is not warranted. The Board has also considered the testimony of the Veteran connecting his cancer to service or a service-connected disability, but as a lay person, he is not competent to opine as to medical etiology or render medical opinions. Barr, supra. The Board acknowledges that the Veteran is competent to testify as to observable symptoms, but finds that his opinion as to the cause of the disability simply cannot be accepted as competent evidence. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1131, 1336 (Fed. Cir. 2006). In sum, the post-service medical evidence of record shows that the first evidence of squamous cell carcinoma was years after the Veteran's separation from active duty. In addition, the weight of the competent medical evidence is against a finding that the Veteran's cancer involves the respiratory system, is etiologically related to any incident of military service (to include herbicide exposure), or was incurred secondary to a service-connected disability. Accordingly, the Board must conclude that the preponderance of the evidence is against the claim and it is denied. 38 U.S.C.A. § 5107(b) (West 2002). Disorder of the Salivary Glands The Veteran contends that service connection is warranted for a disorder of the salivary glands as he incurred the disability after undergoing chemotherapy for his squamous cell carcinoma of the right neck. He testified in August 2010 that his radiation treatment for cancer damaged his saliva glands and has caused a chronic dry mouth and difficulties swallowing. The competent medical evidence establishes that the Veteran incurred a disorder of the salivary glands as a result of chemotherapy treatments from November 2005 to January 2006. Private clinical records document complaints of dry mouth, thickened saliva, and difficulty swallowing throughout the Veteran's course of chemotherapy and his private oncologist consistently noted that these symptoms were associated with the radiation treatments. An August 2008 VA ENT examiner also diagnosed sicca syndrome, laryngitis, pharyngitis, and a loss of the sense of taste and smell and found the conditions were the result of the Veteran's past radiotherapy. Although the competent evidence clearly demonstrates a link between the Veteran's current complaints and his cancer, as discussed above, service connection is not warranted for squamous cell carcinoma of the right neck. Therefore, service connection for the Veteran's claimed disorder of the salivary glands is not possible on a secondary basis. See 38 C.F.R. § 3.310. The Board must also determine whether service connection is warranted for the Veteran's salivary gland disorder as directly due to service. The Veteran has not contended that he experienced any symptoms of mouth or salivary gland problems during military service. Service treatment records are also negative for complaints or treatment related to the disability on appeal and the Veteran's mouth was normal at the December 1990 retirement examination. There is also no evidence of dry mouth, thickened saliva, or difficulties swallowing until November 2005, when the Veteran began chemotherapy for cancer. The record does not demonstrate the presence of a nexus between the Veteran's claimed disability and any incident of active duty service, to include herbicide exposure or a report of continuity of symptoms since service. Therefore, service connection for a disorder of the salivary glands as directly due to service is not warranted. Tooth Loss The Veteran contends that service connection is warranted for several missing teeth as they were extracted prior to the start of his chemotherapy and radiation treatment for squamous cell carcinoma. VA treatment records show that the Veteran's oncologist recommended the extraction of several teeth following an October 2005 consultation, and in November 2005, nine of the Veteran's teeth and roots were removed by a VA dentist. The August 2008 VA ENT examiner noted that the Veteran's dental condition prior to the extraction of his teeth was poor with many previously missing teeth. If the remaining teeth had not been removed before the Veteran began radiation treatment, he would have lost considerably portions of the mandible to osteoradionecrosis. The record therefore establishes that nine of the Veteran's teeth (identified in the treatment records as teeth #1, 2, 4, 5, 25, 26, 27, 28, and 32) were extracted in November 2005 in anticipation of radiation therapy to treat squamous cell carcinoma of the right neck. However, as service connection is not warranted for squamous cell carcinoma of the right neck, service connection for the Veteran's missing teeth is not possible on a secondary basis. See 38 C.F.R. § 3.310. There is also some evidence indicating that the Veteran had several teeth extracted during active duty service. The Board must therefore consider whether service connection is warranted for any of the claimed missing teeth as directly due to service. Initially, the Board notes that dental disabilities are treated differently from medical disabilities in the VA benefits system. Generally, treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are not considered disabling conditions and, therefore, they may not be service connected except for the purpose of establishing entitlement to VA outpatient dental treatment as provided in 38 C.F.R. § 3.381(a). In other words, in general, replaceable missing teeth and periodontal disease are not considered disabilities for purposes of VA compensation. The exceptions to the general rule are listed under 38 C.F.R. § 4.150, Diagnostic Codes 9900 through 9916. Specifically, under Diagnostic Code 9913, which governs ratings of 'loss of teeth, due to loss of substance of body of maxilla or mandible without loss of continuity,' certain missing teeth may be compensable for disability rating purposes. 38 C.F.R. § 4.150, Diagnostic Code 9913. Ratings for missing teeth 'apply only to bone loss through trauma or disease such as osteomyelitis, and not to the loss of the alveolar process as a result of periodontal disease, since such loss is not considered disabling'. Id. Thus, service connection is warranted if the record establishes trauma or disease has caused a loss of substance of the body of the maxilla or mandible resulting in a loss of teeth. Service and post-service treatment records document several dental problems and missing teeth, but do not establish the presence of a disease or trauma that caused a loss of substance of the body of the maxilla or mandible in accordance with 38 C.F.R. § 4.150. The Veteran had several teeth extracted during service; in June 1968, tooth #19 was removed and teeth # 14, 17, 18, and 20 were extracted 10 years later in July and August 1978. The Veteran also lost tooth #7 in a motor vehicle accident in July 1983. He was referred for further dental treatment as a result of the motor vehicle accident, and the treating dentist noted in November 1983 that the accident also caused trauma to the anterior mandible and subluxed several teeth in the surrounding area. The teeth were moved and repaired over the next several years. The December 1990 retirement examination does not indicate that a dental examination was performed. VA treatment records from the Alexandria VAMC document further findings of poor dental hygiene and, as discussed above, the Veteran had nine teeth removed in November 2005 prior to the start of chemotherapy treatments. Although service and post-service records document multiple instances of extracted and missing teeth and even trauma to the mandible in July 1983, there is no indication that the Veteran's incurred loss of the substance of the maxilla or mandible such that removal of any teeth was necessary. The Board notes that the Veteran has never claimed that service connection is warranted for any missing teeth as directly due to service. Instead, his statements and testimony throughout the claims period have focused on service connection for missing teeth as secondary to squamous cell carcinoma. The regulations governing dental claims make a fundamental distinction between 'replaceable missing teeth,' see 38 C.F.R. § 3.381(a), and teeth lost as a result of loss of substance of body of maxilla or mandible due to trauma or disease such as osteomyelitis, and not loss of the alveolar process as a result of periodontal disease. See 38 C.F.R. § 4.150; Simington v. West, 11 Vet. App. 41, 44 (1998). In this case, there is no evidence or allegation of trauma causing a loss of substance and the Veteran has never been diagnosed with a bone disease such as osteomyelitis to account for his missing teeth. Thus, the Veteran does not have dental disorder that is eligible for service connection and the claim must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002)) defined VA's duties to notify and assist a veteran in the substantiation of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) and that the claimant is expected to provide. Pelegrini v. Principi (Pelegrini II), 18 Vet. App. 112, 120-21 (2004), see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In this case, notice fulfilling the requirements of 38 C.F.R. § 3.159(b) was furnished to the Veteran in January 2006, June 2006, and November 2010 letters. The Veteran also received notice regarding the disability-rating and effective-date elements of the claims in the June 2006 and November 2010 letters. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice should be given before an initial AOJ decision is issued on a claim. Pelegrini II, 18 Vet. App. at 119-120. While complete VCAA notice was provided after the initial adjudication of the claims, this timing deficiency was remedied by the issuance of VCAA notice followed by readjudication of the claims. Mayfield v. Nicholson, 444 F. 3d 1328 (Fed. Cir. 2006). The claims were most recently readjudicated in the February 2012 SSOC. Therefore, any timing deficiency has been remedied. VA is also required to make reasonable efforts to help a claimant obtain evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to a claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA has obtained records of treatment reported by the Veteran, including service treatment records, records of VA treatment, records from the Social Security Administration (SSA), and private medical records. Additionally, the Veteran was provided proper VA examination and opinions in August 2008 in response to his claims. The Board also finds that VA has complied with the November 2010 remand orders of the Board. In response to the Board's remand, copies of records from the SSA and the Alexandria VAMC were added to the claims file. The case was then readjudicated in February 2012. Therefore, VA has complied with the remand orders of the Board. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. ORDER Entitlement to service connection for squamous cell carcinoma of the right neck, including due to herbicide exposure and secondary to a service-connected splenectomy and calcified paratracheal lymph nodes, is denied. Entitlement to service connection for a disorder of the salivary glands, to include as secondary to squamous cell carcinoma of the right neck, is denied. Entitlement to service connection for tooth loss, to include as secondary to squamous cell carcinoma of the right neck, is denied. REMAND The Board finds that additional development is necessary before a decision may be rendered with respect to the claim for entitlement to service connection for bilateral hearing loss. Although the Veteran contends that his hearing loss was incurred due to chemotherapy treatments associated with squamous cell carcinoma, the record contains evidence indicating that the Veteran may have incurred some hearing loss due to noise exposure during active duty service. Service treatment records show that the Veteran manifested some decrease in hearing acuity during active duty. An audiogram performed in June 1990 documented the Veteran's exposure to hazardous noise exposure, and the December 1990 retirement examination showed some worsening of the Veteran's hearing when compared to the April 1968 enlistment examination. Although the August 2008 VA ENT examiner noted that the Veteran's hearing was normal at the time of his discharge from the military, the examiner also noted the presence of a noise-induced hearing curve prior to the Veteran's radiation-induced hearing loss. A November 2005 audiological examination performed at the VAMC to establish a baseline of the Veteran's hearing before the start of chemotherapy also demonstrated mild to moderate sensorineural bilateral hearing loss. The record therefore indicates that the Veteran may have incurred some noise-related hearing loss as a result of active duty service before beginning chemotherapy in November 2005. A VA audiological examination is necessary to determine the extent of any hearing loss that may have been associated with active service. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA audiological examination with an appropriate examiner. The claims file must be reviewed by the VA examiner. After review of the entire record, including the service treatment records, the examiner should determine whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent), that the Veteran incurred any bilateral hearing loss due to an incident of active duty service, to include hazardous noise exposure. If the examiner determines that the Veteran incurred a bilateral hearing loss disability due to active duty service, an opinion should be provided differentiating between the level of hearing loss due to service and any hearing loss incurred due to chemotherapy treatment from November 2005 to January 2006, if possible. A full rationale (i.e. basis) for all expressed opinions must be provided. 2. Readjudicate the claim on appeal. If the benefits sought on appeal are not fully granted, issue a SSOC before returning the case to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This 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). ______________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs