Citation Nr: 1326165 Decision Date: 08/16/13 Archive Date: 08/26/13 DOCKET NO. 09-32 812 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a rating in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD) with major depression. 2. Entitlement to service connection for prostate cancer and/or benign prostatic hypertrophy, to include as due to herbicide exposure. 3. Entitlement to service connection for bronchitis, to include as due to herbicide exposure and/or ischemic heart disease. 4. Entitlement to service connection for sleep apnea, to include as due to ischemic heart disease. 5. Entitlement to service connection for swelling of joints in the upper extremities. 6. Entitlement to service connection for swelling of joints in the lower extremities. 7. Whether new and material evidence has been presented to reopen a service connection claim for an atrial fibrillation and hypertension with mitral valve insufficiency and, if so, whether service connection may be granted. 8. Whether new and material evidence has been presented to reopen a service connection claim low back disorder and, if so, whether service connection may be granted. 9. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities, to include as due to herbicide exposure or as secondary to service-connected ischemic heart disease. 10. Entitlement to an initial rating in excess of 30 percent for service-connected ischemic heart disease. 11. Entitlement to an effective date prior to November 24, 2004, for service-connected ischemic heart disease. 12. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). ATTORNEY FOR THE BOARD Laura E. Collins, Associate Counsel INTRODUCTION The Veteran had active service from January 1969 to August 1970, including service in the Republic of Vietnam from August 1969 to August 1970. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in September 2008, July 2010, and June 2011 by the Department of Veterans Affairs (VA) Regional Office (RO). The September 2008 rating decision denied service connection for peripheral neuropathy of the lower extremities. The July 2010 rating decision denied service connection for prostate cancer, bronchitis, swelling of joints in the upper and lower extremities, and sleep apnea; declined to reopen claims for service connection for atrial fibrillation with hypertension and low back disorder; and confirmed and continued a 50 percent rating for PTSD with major depression. The June 2011 rating decision granted service connection for ischemic heart disease (IHD) and assigned a 30 percent disability rating effective November 24, 2004. In a February 2001 rating decision the RO granted service connection for PTSD with major depression and assigned a 50 percent disability evaluation. Within one year of this determination, the Veteran did not express disagreement with this initial disability evaluation, nor was any relevant new and material evidence, medical or lay, physically or constructively received by VA prior to the expiration of the appellate period. See 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.156(b); 20.201 (2012); Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2010). As such, the February 2001 rating action became final. In a May 2011 decision, the Board denied service connection for 11 separate issues. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In a June 2012 Memorandum Decision, the Court vacated and remanded the Board's May 2011 decision with respect to the issues of service connection for peripheral neuropathy of the lower extremities. The Court affirmed the Board's May 2011 decision with respect to the remaining issues. In December 2012, the Board remanded those two claims for additional development pursuant to the Memorandum Decision. The case now returns for further appellate review. In August 2010 the Veteran testified before a Decision Review Officer. A transcript has been associated with the claims file. The Board notes that the RO reopened the Veteran's claims of entitlement to service connection for atrial fibrillation with hypertension and low back pain and denied them on the merits in the November 2007 rating decision. However, prior to consideration of the Veteran's claims on the merits, the Board is required to consider the issue of finality, and as such, the issues has been characterized as shown on the title page. See 38 U.S.C.A. §§ 5108, 7104(b) (West 2002); Bernard v. Brown, 4 Vet. App. 384, 390-92 (1993). The Court has held that "a claimant's identification of the benefit sought does not require any technical precision." Brokowski v. Shinseki, 23 Vet. App. 79, 85 (2009); see also Ingram v. Nicholson, 21 Vet. App. 232, 256-57 (2007). Reading the material sympathetically, the Board finds the Veteran's claim for prostate cancer was intended to encompass his current diagnosis of benign prostatic hypertrophy (BPH). Similarly, the Board finds that the Veteran's claims for "heart condition" and "chest disability," adjudicated as "atrial fibrillation and hypertension," were intended to include his diagnosed mitral valve insufficiency. The claims have been recharacterized on the title page accordingly. The issue of entitlement to a TDIU was not certified for appeal. However, when evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for a TDIU will be considered part of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447 (2009). As the evidence suggests that the Veteran may be unemployable due to symptoms of his service-connected PTSD and ischemic heart disease, the issue of entitlement to a TDIU has been raised and is within the jurisdiction of the Board. In addition to the paper claims file, there is a paperless, electronic claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are relevant to the issues on appeal. Thus, any future consideration of this Veteran's case should take into account the existence of this electronic record. As discussed in further detail below, the Board is reopening the claims for service connection for atrial fibrillation with hypertension and mitral valve insufficiency and low back disorder because new and material evidence has been received; however, as further development is needed prior to adjudication, the merits of the issues are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. In addition, the issues of service connection for 1) bronchitis, 2) sleep apnea, 3) swelling of joints in the lower extremities, and 4) peripheral neuropathy; and 5) higher rating for ischemic heart disease are addressed in the REMAND portion of the decision below and are also REMANDED to the RO via the AMC, in Washington, D.C. FINDINGS OF FACT 1. The evidence shows that since May 29, 2009, the Veteran's service-connected PTSD with major depression has rendered him unable to secure or follow a substantially gainful occupation. 2. The preponderance of the evidence weighs against a finding that the Veteran is currently diagnosed with prostate cancer. His BPH manifested many years after his discharge from service, and is not otherwise shown to be etiologically related to service. 3. The preponderance of the evidence weighs against a finding that that the Veteran currently suffers from a disorder associated with swelling of the joints of the upper extremities. The preponderance of the evidence shows that the Veteran's swelling of joints in the upper extremities manifested many years after his discharge from service and is not otherwise etiologically related to service. 4. The Veteran's claim for service connection for atrial fibrillation with hypertension was previously denied in November 2007 by the RO. The Veteran did not appeal and the decision became final. 5. The additional evidence presented since the previous final denial of the claim for service connection for atrial fibrillation with hypertension and mitral valve insufficiency raises a reasonable possibility of substantiating the Veteran's claim for service connection. 6. The Veteran's claim for service connection for low back disorder was previously denied in November 2007 by the RO. The Veteran did not appeal and the decision became final. 7. The additional evidence presented since the previous final denial of the claim for service connection for low back disorder raises a reasonable possibility of substantiating the Veteran's claim for service connection. 8. On September 8, 1998, the Veteran, a Nehmer class member, filed an original claim for service connection for ischemic heart disease. CONCLUSIONS OF LAW 1. The criteria for a TDIU due to PTSD, i.e., a 100 percent rating, have been met, effective May 29, 2009. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.340, 4.16(a), 4.130 (2012). 2. The criteria for service connection for prostate cancer and benign prostatic hypertrophy have not been met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 3. The criteria for service connection for swelling of the joints of the upper extremities have not been met, to include as secondary to herbicide exposure. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). 4. The November 2007 RO rating decision that denied service connection for atrial fibrillation with hypertension is final. 38 U.S.C.A. §§ 7105(c) (West 2002); 38 C.F.R. §§ 20.1103 (2012). 5. New and material evidence has been received to reopen a claim of entitlement to service connection for atrial fibrillation with hypertension and mitral valve insufficiency. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 6. The November 2007 RO rating decision that denied service connection for low back disorder is final. 38 U.S.C.A. §§ 7105(c) (West 2002); 38 C.F.R. §§ 20.1103 (2012). 7. New and material evidence has been received to reopen a claim of entitlement to service connection for low back disorder. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 8. The criteria for an effective date of September 8, 1998, for the award of service connection for ischemic heart disease are met. 38 U.S.C.A. §§ 1154(a), 5107(b), 5110, (West 2002); 38 C.F.R. §§ 3.102, 3.816, 3.400 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Board's decision herein to reopen the claims for service connection for atrial fibrillation with hypertension and low back disorder is completely favorable. The Board's decisions to grant a 100 percent schedular rating for PTSD with major depression and an earlier effective date for IHD are also complete grants. Thus, no further action is required to comply with the Veterans Claims Assistance Act of 2000 (VCAA) and the implementing regulations with respect to those claims. Consideration of the merits of the service connection claims is deferred pending additional development consistent with the VCAA. VA must provide claimants with notice and assistance in substantiating claims for benefits. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). The notice requirements apply to all five elements of a service connection claim, including Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Notice must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on the claim for VA benefits. 38 U.S.C.A. § 5103(a); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Board finds that VA has satisfied its duty to notify. Specifically, with respect to his claim for service connection for prostate cancer and swelling of the joints of the upper extremities, a July 2009 letter, sent prior to the initial unfavorable decision issued in July 2010, advised the Veteran of the evidence and information necessary to substantiate his service connection claims, including as secondary to in-service herbicide exposure, and to establish a disability rating and an effective date. The same letter advised the Veteran of his and VA's respective responsibilities in obtaining the evidence and information. Relevant to the duty to assist, the Veteran's service medical records, personnel records, private treatment records, and VA medical records have been obtained and considered. Pursuant to the December 2012 Board remand, the RO obtained VA treatment records dated after May 2011 and associated them with the electronic claims file. Also pursuant to the Board remand, in a December 2012 letter, the RO gave the Veteran the opportunity to identify any additional providers who treated his peripheral neuropathy. Pertinent to the claims decided herein, he has not identified any additional outstanding records that have not been requested or obtained. The Board finds that the AOJ substantially complied with the December 2012 remand orders and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The Board acknowledges that the Veteran has not been provided with a VA examination in conjunction with his service connection claims decided below. The evidence fails to show any past or present diagnosis of prostate cancer. Moreover, his service and post-service treatment records fail to suggest that he developed BPH or swelling of the joints of the upper extremities during or soon after service, and the medical evidence of record fails to suggest a nexus. Thus, VA's duty to provide an examination has not been triggered. See McLendon v. Nicholson, 20 Vet. App. 79 (2006) (holding that a VA examination is only warranted when the medical evidence suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits). The Board concludes that all relevant facts have been properly developed and reasonable efforts were made by the VA to obtain evidence necessary to substantiate the Veteran's claims. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Reopening Claims Rating actions are final and binding based on evidence on file at the time the Veteran is notified of the decision and may not be revised on the same factual basis except by a duly constituted appellate authority. 38 C.F.R. § 3.104(a). The Veteran has one year from notification of an RO decision to initiate an appeal by filing a notice of disagreement (NOD) with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C.A. § 7105(b), (c); 38 C.F.R. §§ 3.160(d), 20.200, 20.201, 20.202, 20.302(a). Where a claim of entitlement to service connection has been previously denied and that decision has become final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C.A. § 5108 (West 2002). Moreover, where the prior final decision was an unappealed RO rating decision, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "the statutes make clear that the Board has a jurisdictional responsibility to consider whether it was proper for a claim to be reopened, regardless of whether the previous action denying the claim was appealed to the Board." Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). In making this determination, the Board must review all of the evidence submitted since the last final rating decision. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The Court has held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material. The Court further held that new evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary's duty to assist by providing a medical opinion. Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and viewed the phrase "raises a reasonable possibility of substantiating the claim" as enabling rather than precluding reopening. The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which does not require new and material evidence as to each previously unproven element of a claim. Shade, supra; see also Evans v. Brown, 9 Vet. App. 273, 284 (1996) (the newly presented evidence need not be probative of all the elements required to award the claim; rather it need only be probative in regard to each element that was a specified basis for the last disallowance). Newly submitted evidence is presumed to be credible for the purpose of determining whether evidence is sufficiently new and material. See Justus v. Principi, 3 Vet. App. 510, 513 (1992); Kutscherousky v. West, 12 Vet. App. 369, 371 (1999). The prior evidence considered in the final November 2007 denial consisted of the Veteran's service treatment records, private treatment records from Parkland Hospital dated March 1988, the Veteran's lay statements, a July 2007 VA general medical examination, and VA treatment records dated in 1973, from August 1974 to May 1977, and from May 1995 to July 2007. New evidence added to the record since the November 2007 rating decision consists of numerous lay statements from the Veteran, a February 2011 VA IHD examination, service personnel records, a private occupational evaluation dated May 2003, and VA treatment records dated from July 2007 to June 2009, as well as from December 2010 to December 2012. This evidence is all "new" as it was not previously submitted to agency decision makers. The regulation at 38 C.F.R. § 3.156(c) (2012) provides that, under certain circumstances, if relevant official service department records are added to the file after VA issues a decision on a claim, VA will reconsider the claim. Additional service personnel records were associated with the file in June 2010. These are official service department records that existed at the time of the prior denial but had not been associated with the claims file. However, these records do not contain information relevant to the claims for service connection for atrial fibrillation with hypertension or low back disorder. Thus, VA is not required to reconsider the claims under 38 C.F.R. § 3.156(c). A. Atrial fibrillation with hypertension and mitral valve insufficiency The Veteran first sought service connection for chest pains in September 1970, one month after discharge from service and a rating action denied his claim in October 1970. The Veteran did not file an NOD with the October 1970 rating action and no additional evidence pertinent to the issue was physically or constructively associated with the claims folder within one year of the rating decision. 38 C.F.R. § 3.156(b) (2012); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); Buie. Thus, the October 1970 rating decision became final based on the evidence then of record. 38 U.S.C.A. §§ 7104, 7105 (West 2002); 38 C.F.R. § 20.1105 (2012). In September 1998 the Veteran filed a claim for heart condition and hypertension. In January 1999 the RO denied the claim and the Veteran filed a timely NOD and Substantive Appeal. However, in January 2001, prior to adjudication, he withdrew the claim for "heart disease and hypertension." In January 2007 he filed to reopen a claim for service connection for "chest disability." In a November 2007 rating decision the RO reopened and denied service connection on the merits for atrial fibrillation with hypertension. The Veteran did not file an NOD with the November 2007 rating decision. New evidence pertinent to the issue was physically associated with the claims folder within one year of the rating decision. Specifically, in April 2008 VA received VA treatment records that contained extensive notes related to a March 2008 hospitalization for cardiac symptoms. However, while this was new evidence that had not been considered in the November 2007 decision, it was not "material." See 38 C.F.R. § 3.156(b); Bond; Buie. The basis of the November 2007 final denial was the absence of evidence that atrial fibrillation with hypertension was incurred in or aggravated by military service. The cardiac hospitalization showed current disability, but in no way addressed a nexus between the current disability and service. As such, it did not relate to an unestablished fact necessary to substantiate the claim. Because the evidence was not material, the November 2007 rating action became final based on the evidence then of record. 38 U.S.C.A. §§ 7104, 7105; 38 C.F.R. § 20.1105. Where, as here, a claim of entitlement to service connection has been previously denied and that decision has become final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C.A. § 5108. As discussed earlier, "new" evidence has been submitted to reopen the previously denied claim. Thus, the Board must now consider whether it is "material." The basis of the November 2007 final denial was the absence of evidence that atrial fibrillation with hypertension was incurred in or aggravated by military service. In June 2011, after the November 2007 final prior denial, the Veteran was granted service connection for IHD. The new evidence includes statements by the Veteran asserting that his atrial fibrillation with hypertension were caused or aggravated by his service-connected IHD. A new VA treatment record dated April 2009 states that the Veteran's atrial fibrillation symptoms worsened to daily recurrence in 2004. The Board notes that this is the same year in which the RO found a diagnosis of septal infarct, establishing IHD. The absence of evidence of aggravation was one of the elements of service connection upon which the prior denial was based. Considering the low threshold of 38 C.F.R. § 3.156(a) under Shade and resolving doubt in favor of the Veteran, the Board finds that this evidence relates to an unestablished fact necessary to substantiate the claim and raises a reasonable possibility of substantiating the Veteran's claim that the his atrial fibrillation with hypertension and mitral valve insufficiency were caused or aggravated by his IHD. It is therefore material and sufficient to reopen the previously-denied claim. The Board reopens the Veteran's claim of entitlement to service connection for atrial fibrillation with hypertension for a de novo review on the merits. 38 U.S.C.A. §§ 5108, 7105; 38 C.F.R. § 3.156. The Board notes that the RO reopened the Veteran's claim in the November 2007 rating decision and denied it on the merits. The Board herein grants the Veteran's claim to the extent that it is reopened. Therefore, he is not prejudiced by the Board's actions herein. Bernard, 4 Vet. App. at 390-92. B. Low back disorder The Veteran first sought service connection for low back disorder in April 1977 and a rating action denied his claim in June 1977. The Veteran did not file an NOD and no additional evidence pertinent to the issue was physically or constructively associated with the claims folder within one year of the rating decision. 38 C.F.R. § 3.156(b); Bond; Buie. Thus, the June 1977 rating decision became final based on the evidence then of record. 38 U.S.C.A. §§ 7104, 7105; 38 C.F.R. § 20.1105. In August 1984 the Veteran requested his claim be reopened, and in the same month the RO declined to reopen it. The Veteran did not file an NOD and no additional evidence pertinent to the issue was physically or constructively associated with the claims folder within one year of the rating decision, so it became final. In July 1997 the Veteran requested his claim be reopened and in November 1997 the RO declined to reopen it. The Veteran filed a timely NOD and Substantive Appeal. However, in January 2001, prior to adjudication, he withdrew the claim for low back disorder. In a November 2007 rating decision the RO reopened and denied service connection on the merits for low back disorder. The Veteran did not file an NOD with the November 2007 rating decision and no additional evidence pertinent to the issue was physically or constructively associated with the claims folder within one year of the rating decision. See 38 C.F.R. § 3.156(b); Bond; Buie. Thus, the November 2007 rating decision became final based on the evidence then of record. 38 U.S.C.A. §§ 7104, 7105; 38 C.F.R. § 20.1105. Where, as here, a claim of entitlement to service connection has been previously denied and that decision has become final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C.A. § 5108. As discussed earlier, "new" evidence has been submitted to reopen the previously denied claim. Thus, the Board must now consider whether it is "material." The basis of the November 2007 final denial was the absence of evidence that low back condition was incurred in or caused by military service. The new evidence includes a July 2012 statement by the Veteran asserting that the evidence shows recurrence of low back symptoms during and since service, citing to STRs dated in February 1969 and medical records dated in August 1974, and continuing complaints of back pain to the present. Considering the low threshold of 38 C.F.R. § 3.156(a) under Shade and resolving doubt in favor of the Veteran, the Board finds that the history of back complaints in service and recurrent and continuing low back symptoms, read together with the Veteran's recent statements, are sufficient to raise a reasonable possibility of substantiating the Veteran's claim that his low back disorder was incurred in or aggravated by service. It is therefore material and sufficient to reopen the previously-denied claim. The Board reopens the Veteran's claim of entitlement to service connection for low back condition for a de novo review on the merits. 38 U.S.C.A. §§ 5108, 7105; 38 C.F.R. § 3.156. The Board notes that the RO reopened the Veteran's claim in the November 2007 rating decision and denied it on the merits. The Board herein grants the Veteran's claim to the extent that it is reopened. Therefore, he is not prejudiced by the Board's actions herein. Bernard. III. Service Connection Claims Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability, in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.304. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, as this Veteran did, service connection for certain diseases, including prostate cancer, may be granted based on presumed exposure to certain herbicide agents, even though there is no record of such disease during service. Presumed exposure to an herbicide applies for a Veteran who had active military, naval, or air service for at least 90 days, during the period beginning on January 9, 1962 and ending on May 7, 1975, that included service in the Republic of Vietnam or other locations if the conditions of service involved duty or visitation in Vietnam. 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307, 3.309(e), 3.313. The Veteran's service in the Republic of Vietnam from August 1969 to August 1970 has been confirmed. Moreover, the RO conceded exposure to Agent Orange in the July 2010 rating decision on appeal. When there is an approximate balance of evidence for and against the issue, all reasonable doubt will be resolved in the Veteran's favor. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). A. Prostate Cancer and Benign Prostatic Hypertrophy The Veteran contends that his diagnosis of BPH indicates prostate cancer and that this condition was the result of exposure to Agent Orange in Vietnam. There is no evidence that the Veteran has ever been diagnosed with prostate cancer. The Veteran's service treatment records (STRs) are silent for prostate complaints. The separation examination report, dated August 1970, shows a normal genitourinary system and no diagnoses, history, or treatment of prostate problems. The Veteran's post-service treatment records are silent with respect to prostate cancer, containing no clinical assessments, impressions, or findings thereof. The evidence of record does not show a current disability of prostate cancer. Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Therefore, the Board finds that the claim for service connection for prostate cancer must be denied because the preponderance of the evidence of record is against a finding that the Veteran has ever been diagnosed with prostate cancer. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. The Board has found that the Veteran's service connection claim for prostate cancer was intended to encompass his current diagnosis of BPH. The VA medical records establish that the Veteran has that current disability. Specifically, a VA treatment note dated September 1974 shows objective evidence of enlarged prostate with a diagnosis of acute prostatitis. A VA treatment note dated May 1999 shows the first diagnosis of BPH; this diagnosis has continued to the present. While the Veteran's exposure to Agent Orange has been conceded, BPH is not one of the conditions that VA has determined to have a positive association with exposure to herbicides. The presumptive provisions of 38 C.F.R. § 3.307 are specifically limited to enumerated chronic diseases listed in 38 C.F.R. § 3.309, and BPH is not one of the enumerated diseases. Therefore, his service connection claim must fail on the basis of the presumptive regulations. Notwithstanding the foregoing presumption provisions, the Federal Circuit has determined that the presumptive service connection procedure does not preclude a Veteran from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039, 1044 (Fed. Cir. 1994). The Veteran has not actually contended that his BPH arose during service. STRs are negative for any complaints, treatment, or diagnoses referable to his BPH. The separation examination report, dated August 1970, shows a normal genitourinary system and no diagnoses, history, or treatment of prostate problems. The earliest medical evidence of record of any prostate complaint is the September 1974 VA treatment note, and the earliest treatment record showing a diagnosis of BPH is dated May 1999. There is no medical evidence suggesting a nexus between the current disability and service. Direct service connection may not be granted without evidence of in-service incurrence or aggravation of a disease or injury. The Board has found that there is no evidence of in-service incurrence or aggravation and the Veteran has not contended that there was any other in-service cause of his BPH. As there is no medical evidence of record suggesting a connection between in-service exposure to herbicides and the Veteran's BPH, and no evidence of any manifestations or symptoms attributable to BPH during service or until years after his discharge from service, the Board finds no basis to grant service connection. The Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for BPH. Therefore, his claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert. B. Swelling of joints in the upper extremities The Veteran seeks entitlement to service connection for swelling of joints in the upper extremities. The Board notes that the Court's June 2012 Memorandum Decision affirmed the Board's May 2011 denial of claims for service connection for peripheral neuropathy of the upper extremities and bilateral hand conditions. As noted above, the Veteran's exposure to herbicide agents, to include Agent Orange, during service has been conceded. Nonetheless, the preponderance of the evidence weighs against the Veteran's claim because he is not shown to currently suffer from a disorder involving the upper extremities that is enumerated in the regulations as a disease associated with herbicide exposure. 38 C.F.R. § 3.309(e). Therefore, his service connection claim must fail on the basis of the presumptive regulations. Notwithstanding the foregoing, the Federal Circuit has determined that the presumptive service connection procedure does not preclude a Veteran from establishing service connection with proof of actual direct causation. Combee. The Veteran has not actually contended that his swelling of the joints of the upper extremities arose during service or to a compensable degree in the first post-service year. The Veteran's STRs are devoid of any complaints, findings, or treatment for swelling of the upper extremities and his upper extremities were clinically evaluated as normal at the August 1970 separation examination. The first indication of any upper extremity swelling is in 1998, more than 25 years after service. Instead, the Veteran asserts that his upper extremity swelling is the result of presumed in-service herbicide exposure. A post-service private treatment record dated October 1998 documents an episode of sudden swelling in the left elbow. The Veteran reported no past similar episodes. The physician observed the left posterior elbow had a fluid-filled soft nodule without erythema or crepitus. VA treatment records show that in September 2012 the Veteran had constant sharp left elbow pain and swelling at a 9/10 that worsened with activity and was improved by nothing. The Veteran reported similar pain about 10 years ago where he could not lift the arm up. The physician observed restricted range of motion, swelling in the joint, pain in soft tissue portion of elbow, no bony prominence, and tenderness. The joint was warmer than surrounding skin, there was no evidence of erythema, crepitus, drainage, or focal evidence of trauma. He assessed "mono-articular arthopathy: unclear etiology no evidence of trauma. Diagnoses include bursitis of alecronon process vs. gouty joint vs. septic joint." X-ray showed possible bone spurring in the left elbow consistent with degenerative joint disease. A December 2012 VA treatment record shows resolved right elbow pain with the note "?bursitis?" A final diagnosis apparently was never made. No subsequent or earlier treatment records included in the record show treatment for, or diagnosis of, a clearly identified disorder that is manifested by swelling of either upper extremity. As a lay person, the Veteran is competent to testify with respect to facts and symptoms that are capable of lay observation. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Therefore, he is competent to report his experience of upper extremity swelling and pain. His assertions are considered credible as they are consistent with the October 1998 private treatment record and September 2012 and December 2012 VA treatment records. It does not appear that the Veteran's upper extremity swelling has been attributed to any particular disability by a competent medical professional. The Veteran is not shown to be diagnosed with any disorder which may affect the upper extremities and has also been determined by the Secretary to be associated with exposure to herbicide agents. Further, the Veteran himself has not asserted, or otherwise indicated, that any disorder affecting the upper extremities is related to herbicide exposure except via presumption. Pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. Sanchez Benitez v. West, 13 Vet. App. 282, 285 (1999). However, even if the Board resolves doubt in favor of the Veteran and finds that he has a current disability manifested by upper extremity swelling, there is no evidence that such a disability is related to service. There is no medical evidence linking the swelling of the upper extremities to service. The September 2012 VA treatment record is the only medical record addressing its cause and that physician found the etiology was unclear. The Veteran has contended on his own behalf that his upper extremity swelling is related to his military service. Lay evidence may be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to." Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). The Board finds that the question regarding the potential relationship between the Veteran's upper extremity swelling and any instance of his military service to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg, the claimant is not competent to provide evidence as to more complex medical questions). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the nexus issue in this case falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Veteran does not possess the medical knowledge to attribute his swelling of joints of the upper extremities to any specific instance of his military service. Here, while the Veteran is competent to describe his swelling and pain symptoms, the Board accords his statements regarding the etiology of the claimed disorder little probative value as he is not competent to opine on such a complex medical question. In summary, swelling of joints of the upper extremities was not shown in service or for decades thereafter, and there is no probative evidence indicating that it is related to service. Accordingly, the preponderance of the evidence is against the claim, and service connection for peripheral neuropathy is denied. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert. IV. Earlier Effective Date Claim Generally under the applicable criteria, the effective date of an award based on an original claim shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C.A. § 5110(a). In cases involving presumptive service connection due to herbicide exposure, there is an exception to the provisions set forth above. VA has promulgated special rules for the effective dates for the award of presumptive service connection based on exposure to herbicides, pursuant to orders of a United States District Court in the class action of Nehmer v. United States Department of Veterans Affairs. See 38 C.F.R. § 3.816; see also Nehmer v. United States Veterans Administration, 712 F. Supp. 1404 (N.D. Cal. 1989) (Nehmer I); Nehmer v. United States Veterans Administration, 32 F. Supp. 2d. 1175 (N.D. Cal. 1999) (Nehmer II); Nehmer v. Veterans Administration of the Government of the United States, 284 F.3d 1158 (9th Cir. 2002) (Nehmer III). Specifically, a Nehmer class member is defined as a Vietnam veteran who has a "covered herbicide disease." 38 C.F.R. § 3.816. The Veteran served in the country of Vietnam during the Vietnam War era and, therefore, is a "Vietnam veteran" as defined in the regulations. 38 C.F.R. § 3.307(a)(6). According to 38 C.F.R. § 3.816(b)(2) a "covered herbicide disease" includes a disease for which the Secretary of Veterans Affairs has established a presumption of service connection before October 1, 2002 pursuant to the Agent Orange Act of 1991. Ischemic heart disease, to include coronary artery disease, was not added to the list of presumptive disabilities until August 31, 2010. 75 Fed. Reg. 53, 202 (August 31, 2010). Notwithstanding the language of 38 C.F.R. § 3.816, however, notice accompanying the issuance of the final August 31, 2010 rule specifically notes the Nehmer provisions apply to the newly covered diseases, to include coronary artery disease. Id. Accordingly, the Board concludes the Veteran is a "Nehmer class member" as defined in the law. Certain effective dates apply if a Nehmer class member was denied compensation for a covered herbicide disease between September 25, 1985, and May 3, 1989; or if there was a claim for benefits pending before VA between May 3, 1989, and the effective date of the applicable liberalizing law. 38 C.F.R. § 3.816(c)(1)-(3). However, if the requirements of 38 C.F.R. § 3.816(c)(1)-(2) are not met, the effective date shall be assigned according to 38 C.F.R. § 3.400. 38 C.F.R. § 3.816(c)(4). Certain additional exceptions are set forth that are not pertinent to this appeal. In this case, the record reflects that the Veteran served in the Republic of Vietnam and was granted presumptive service connection for ischemic heart disease based on presumed exposure to herbicides during such service. As such, the provisions of 38 C.F.R. § 3.816 apply. If a Nehmer class member is entitled to disability compensation for a covered herbicide disease, the effective date of the award will be the later of the date such claim was received by VA or the date the disability arose. 38 C.F.R. § 3.816(c)(2). The Veteran sought service connection for chest pains in September 1970, one month after discharge from service and a rating action denied his claim in October 1970. As discussed earlier, this denial became final. No evidence of ischemic heart disease was submitted in connection with this claim; only a complaint of chest pain. In his July 2011 NOD, the Veteran asserted that he is entitled to an earlier effective date of May 11, 1998. On May 11, 1998, the Veteran filed a claim for non-service-connected pension for heart condition. The Board notes at the outset that the May 1998 claim for non-service-connected pension for heart condition sought entitlement to a different benefit than the Veteran's claims for service connection. 38 C.F.R. § 3.151(a) (2012). While a claim for pension may also be considered a claim for compensation, in this case the Veteran did not use the specific claim form, and moreover, his language very clearly only claimed non-service-connected pension. Id; see also Stewart v. Brown, 10 Vet. App. 15 (1997). Accordingly, May 11, 1998, cannot be the date of claim for ischemic heart disease. On September 8, 1998, the Veteran filed a claim for service connection for heart condition. This is the earliest claim that can be construed as seeking service connection for ischemic heart disease. In January 1999 the RO denied the claim and the Veteran timely appealed, but then withdrew the claim for "heart disease" in January 2001, prior to adjudication. Generally, once an appeal has been withdrawn, it no longer can constitute the date of claim for earlier effective date purposes. See Hanson v. Brown, 9 Vet. App. 29, 31-32 (1996). Here however, in light of Nehmer and the specific provisions set forth in 38 C.F.R. § 3.816, there is an exception to that general rule. The medical evidence shows that the Veteran received treatment since September 8, 1998, for heart problems and underwent cardiac catheterization. Further, in July 2000 physicians noted that a myocardial infarction needed to be ruled out. A July 2003 VA examination noted a history of angina. A November 24, 2004 VA treatment note states that an EKG shows "septal infarct (old)." VA treatment notes dated April 2004 to August 2008 include "Chronic Ischemic Heart Disease Not Elsewhere Classified" in the Past Medical History list. It is not clear when the septal infarct or chronic IHD disabilities arose, but it is clear that it predated July 2003. Again, the proper effective date in the instant case is either the date the Veteran's original claim was received, or the date the disability arose, whichever is later. 38 C.F.R. § 3.816(c)(2). The Veteran filed his original claim on September 8, 1998, and the medical evidence is unclear regarding when the Veteran's disability first arose. Resolving doubt in the Veteran's favor, the Board finds that September 8, 1998 is the later of the two dates, and therefore is the appropriate effective date under 38 C.F.R. § 3.816(c)(2). IV. Higher Rating Claim Disability evaluations are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. Separate diagnostic codes (DCs) identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Veteran's entire history is reviewed when making disability evaluations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1995). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of his symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the 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. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau, 492 F.3d at 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the Federal Circuit, citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Finally, pursuant to the Court's decision in Rice, a TDIU claim is part of a claim for a higher rating when, as here, the claim is raised by the record or asserted by the Veteran. A. Analysis The Veteran's PTSD with major depression is rated 50 percent disabling. The Veteran contends that throughout the appeal period his psychiatric disability was more severe than the assigned rating and that he is entitled to an increased rating. The December 2009 VA examiner assigned a GAF score of 50 to the Veteran. The GAF is a scale indicating the psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness. GAF scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). A GAF score is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. DSM-IV; Massey v. Brown, 7 Vet. App. 204, 207 (1994). The VA examiner is not permitted to include impairment in functioning due to physical or environmental limitations when assigning a GAF. The VA examination report reflects that in this case the GAF score of 50 reflects a serious impairment in occupational and social functioning that, according to the DSM-1V, indicates the inability to keep a job. The evidence shows that the Veteran has not worked since 1998. The Board finds that the December 2009 VA examination report shows that the Veteran's service-connected psychiatric disability alone is sufficiently severe to produce unemployability. In light of the above, and in the absence of any contradictory medical evidence, the Board finds that a grant of a TDIU is warranted throughout the appeal. 38 C.F.R. §§ 4.16(a), 4.130. ORDER Service connection for prostate cancer and benign prostatic hypertrophy are denied. Service connection for swelling of the joints of the upper extremities is denied. New and material evidence having been received, the appeal to reopen a claim of entitlement to service connection for atrial fibrillation with hypertension and mitral valve insufficiency is granted. New and material evidence having been received, the appeal to reopen a claim of entitlement to service connection for low back disorder is granted. An effective date of September 8, 1998, for the award of service connection for ischemic heart disease is granted, subject to the law and regulations governing payment of monetary benefits. A total disability rating based on individual unemployability due to service-connected PTSD, i.e., a 100 percent rating, is granted, effective May 29, 2009, subject to the law and regulations governing payment of monetary benefits. REMAND At the outset, the Board notes that the Veteran has not been provided with VCAA notice that expressly addresses the secondary aspect of his service connection claims for bronchitis, sleep apnea, peripheral neuropathy, and atrial fibrillation with hypertension and mitral valve insufficiency. In his July 2012 substantive appeal, he contended that his bronchitis, sleep apnea, atrial fibrillation with hypertension and mitral valve insufficiency, and peripheral neuropathy are secondary to herbicide exposure and/or service-connected ischemic heart disease. Such notices should be provided on remand. The Veteran also seeks service connection for bronchitis, contending that it is secondary to herbicide exposure and/or ischemic heart disease. The STRs show that the Veteran reported a history of chronic cough on induction, however there is no medical notation of a chronic cough on the medical examination report. Accordingly, he is presumed to have been sound on entry to service. The STRs also show complaints of cough in service in March 1969. The post-service treatment records show diagnoses of bronchitis in March 2008 and June 2009. The Board may order an examination when the record shows that the Veteran has a current disability, indicates that this disability may be associated with the Veteran's active service, and does not contain sufficient evidence for the Board to make a decision on the issue. 38 U.S.C.A. § 5103A(d)(2); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The regulations at 38 C.F.R. § 3.159(c)(4) present a low threshold for the requirement that evidence indicate that the claimed disability may be associated with in-service injuries for the purposes of a VA examination. In this case, the Board finds that the in-service complaints of cough and diagnoses of bronchitis during the appeal period, coupled with service connection for ischemic heart disease and conceded exposure to Agent Orange, are sufficient to indicate that disability may have been incurred in or aggravated by service. Therefore, a remand is necessary to afford the Veteran a VA examination to address the etiology of his claimed bronchitis. The Veteran also seeks service connection for sleep apnea, contending that it is secondary to herbicide exposure and/or ischemic heart disease. The Veteran has been diagnosed with obstructive sleep apnea since June 2000, but in a May 2002 treatment record reported that he had experienced symptoms since high school. Taken together with his service-connected ischemic heart disease and conceded exposure to Agent Orange, the Board finds a remand is necessary to afford the Veteran a VA examination to address the etiology of his sleep apnea. 38 C.F.R. § 3.159(c)(4); McLendon. The Veteran also seeks service connection for the swelling of joints and peripheral neuropathy of the lower extremities. STRs show decreased reflexes and strength of the right lower extremity in February 1969. Post-service treatment records show reported numbness in March 1988. Private treatment records show that in September 1998 and October 1998 Lasix was prescribed for observed bilateral leg edema (right greater than left). In May 1999 the Veteran reported ongoing swelling in the lower extremities and Lasix was continued. VA treatment records show that in July 1999 right lower extremity swelling was reported as being ongoing for two years, following a heart catheterization in 1997. In August 2000 right ankle and foot swelling were observed. In May 2003 swelling of the lower extremities was noted in VA treatment records, and a private physician opined that the Veteran's lower extremity edema resulted in work limitations. In June 2008 the Veteran reported bilateral foot numbness since service was noted to have restless leg syndrome. In October 2008 a VA physician observed lower extremity edema without joint swelling and right knee osteoarthritis was diagnosed. An April 2009 VA treatment note shows observed left knee swelling without erythema, heat, or ecchymosis, that the Veteran reported had recurred for many years, usually resolving after one day. The February 2013 examiner found current paresthesias of the big toes bilaterally. While the February 2013 VA examiner found no current peripheral neuropathy in either leg, the Board finds that another examination is necessary to address the neurological and edema symptoms reported by the Veteran during and after service. In light of the Veteran's assertions, the medical evidence, and the potential connection between cardiac catheterization and leg swelling, the Board finds that it is necessary to afford the Veteran another VA examination to address whether his symptoms of the lower extremities, including numbness and swelling, may be related to service, to include as secondary to service-connected ischemic heart disease. The Veteran also seeks service connection for atrial fibrillation with hypertension and mitral valve insufficiency. Post-service treatment records show reported chest pains in September 1970, just one month after separation from service, and a diagnosis of hypertension in 1973. An August 1974 VA treatment record shows a notation of high blood pressure, and in many treatment records the Veteran reports a longstanding history of hypertension going back to the 1970s. He was diagnosed with atrial fibrillation in 1998, and in 2004, the same year that his service connection for ischemic heart disease became effective, his atrial fibrillation symptoms worsened to daily occurrence. In 2004, VA treatment records also showed mild to moderate mitral valve regurgitation (MVR). In November 2008 his MVR was moderate and by April 2009 it was severe and an MVR repair was recommended. In March 2011 it was still severe and repair was still recommended. Based on the foregoing, the Board finds a remand is necessary to afford the Veteran a VA examination to address whether his atrial fibrillation, hypertension, or mitral valve insufficiency may be related to service, to include as secondary to service-connected ischemic heart disease. McLendon. Moreover, VA treatment records indicate that prior to April 2004 the Veteran was treated for cardiac symptoms, including a septal infarct and/or CAD. However, the claims file does not contain VA treatment records dated between January 2001 and April 2004. Therefore, there are potentially outstanding records relevant to his atrial fibrillation, hypertension, or mitral valve insufficiency. Specifically, VA treatment records dated between January 2001 and April 2004 relevant to the Veteran's heart should be obtained and the Veteran should be provided with the opportunity to identify any private providers who treated him for cardiac symptoms prior to April 2004. The Veteran also seeks service connection for low back disorder. STRs include reports in February 1969 of lower lumbar pain and an x-ray showing biconcave deformity of several lumbar vertebrae with a provisional diagnosis of disc syndrome. The same STRs show that the Veteran reported a back injury at age 14, prior to service. However, the medical examination report at induction showed a normal spine and has no notation of any back problems. Therefore, the Veteran's back is presumed to have been sound on entry to service. An STR dated February 5, 1969 states that his back pain was aggravated by basic training. Post-service treatment records show that he has continued to complain of back pain since service, and has been diagnosed by x-ray with biconcavity of disc spaces due to vertical disc herniation. Based on the foregoing, the Board finds a remand is necessary to afford the Veteran a VA examination to address whether his low back disorder may be related to service. McLendon. The Veteran also seeks a higher rating for his service-connected ischemic heart disease. However, the Board has granted an earlier effective date for this condition that must be implemented by the RO. Additionally, on remand it is seeking outstanding potentially relevant treatment records. Thus, a decision by the Board on the Veteran's higher rating claim would, at this point, be premature. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim.). The Veteran indicated that he was treated at Parkland Hospital and the Dallas VAMC from 1970 to 1980 for his back and hypertension. However, the claims file contains only March 1988 records from Parkland Hospital and Dallas VAMC records from August 1974 to May 1977, with a single page from 1973. In June 2000, the Dallas VAMC was requested to provide all records dated from January 1971 to the present and to state if a search revealed no records were available. However, there is no such statement on file. In March 2007, Parkland Hospital was requested to provide records dated 1971 to 1988, but submitted only those from March 1988 without further explanation. The Veteran may also have been treated for his heart at these facilities during this time frame. On remand, records relevant to low back, hypertension, and heart dated from 1970 to 1980 should be requested from both facilities. The record indicates that the Veteran has had regular medical treatment and outpatient mental health treatment at the North Texas Health Care System (HCS) and Dallas VA Medical Center (VAMC). The most recent records associated with the claims file are dated December 2012 and the Veteran may have received treatment in the intervening time. Therefore, on remand, North Texas HCS and Dallas VAMC treatment records dated from December 2012 to the present should be obtained. Finally, in a VA treatment record dated April 2003 the Veteran reported that he had a hearing scheduled for Social Security disability purposes and sought assistance obtaining documentation from his VA physicians regarding his back condition. Accordingly, there may be outstanding Social Security Administration (SSA) records that may be relevant to the Veteran's claims. Such records should be requested on remand. See Golz v. Shinseki, 590 F.3d 1317, 1323 (2010); 38 C.F.R. § 3.159(c)(2) (2012). Accordingly, the case is REMANDED for the following actions: 1. Provide the Veteran with appropriate notice regarding the evidence and information necessary to substantiate his claims of entitlement to service connection for bronchitis, sleep apnea, atrial fibrillation with hypertension and mitral valve insufficiency, and peripheral neuropathy to include as secondary to his service-connected ischemic heart disease and conceded herbicide exposure, in accordance with 38 C.F.R. § 3.310. 2. Ask the Veteran to identify any private providers who treated him for cardiac symptoms prior to April 2004. Then attempt to obtain any outstanding records identified. 3. Obtain relevant treatment records from the North Texas HCS dated from December 2012 to the present. Obtain relevant treatment records from the Dallas VAMC dated from August 1970 to August 1974, from May 1977 to January 1981, from January 2001 to April 2004, and from December 2012 to the present. 4. Obtain treatment records relevant to low back, hypertension, and heart from Parkland Hospital dated from 1970 to 1980. 5. Request copies of any SSA disability benefit determinations as well as copies of the medical records on which such determinations were based. If the records are not available, the claims file should be annotated to reflect such and the Veteran should be notified of such. 6. Schedule the Veteran for an appropriate VA examination to determine whether his claimed bronchitis is related to service. The examiner should review the claims file and note that review in the report. All appropriate tests and studies should be conducted. After examining the Veteran, the examiner should address the following: a) Diagnose all respiratory conditions from which the Veteran currently suffers. b) Provide an opinion as to whether the Veteran's current respiratory conditions, including bronchitis, are at least as likely as not: 1. related to service, including the cough noted in the service treatment records, or 2. caused, at least in part, by the Veteran's service-connected ischemic heart disease, or 3. aggravated, at least in part, by the Veteran's service-connected ischemic heart disease, or 4. caused, at least in part, by the Veteran's Agent Orange exposure? The examiner should presume that the Veteran was sound as to chronic cough on entry to service. A complete rationale for any opinion expressed and conclusion reached should be set forth in the report. 7. Schedule the Veteran for an appropriate VA examination to determine whether his sleep apnea is related to service. The examiner should review the claims file and note that review in the report. All appropriate tests and studies should be conducted. After examining the Veteran, the examiner should provide an opinion as to whether the Veteran's current sleep apnea is at least as likely as not: a) related to or aggravated by service, b) caused, at least in part, by the Veteran's service-connected ischemic heart disease, or c) aggravated, at least in part, by the Veteran's service-connected ischemic heart disease, or d) caused, at least in part, by the Veteran's Agent Orange exposure? The examiner should consider the Veteran's lay statements regarding the onset of his sleep apnea. A complete rationale for any opinion expressed and conclusion reached should be set forth in the report. 8. Schedule the Veteran for an appropriate VA examination to determine whether his symptoms of the lower extremities, including numbness and swelling, are related to service, to include service-connected ischemic heart disease. The examiner should review the claims file and note that review in the report. All appropriate tests and studies should be conducted. After examining the Veteran, the examiner should address the following: a) Diagnose all lower extremity disabilities from which the Veteran currently suffers. b) Provide an opinion as to whether the Veteran's current lower extremity disabilities, including the symptoms of numbness and swelling, are at least as likely as not: 1. related to service, including the neurological symptoms noted in the service treatment records, or 2. caused, at least in part, by the Veteran's service-connected ischemic heart disease, or 3. aggravated, at least in part, by the Veteran's service-connected ischemic heart disease, or 4. caused, at least in part, by the Veteran's Agent Orange exposure? The examiner should consider the Veteran's lay statements regarding the onset of his symptoms. A complete rationale for any opinion expressed and conclusion reached should be set forth in the report. 9. Schedule the Veteran for an appropriate VA examination by a cardiologist to determine whether his atrial fibrillation, hypertension, and/or mitral valve insufficiency are related to service, to include ischemic heart disease and/or PTSD with major depressive disorder. The examiner should review the claims file and note that review in the report. All appropriate tests and studies should be conducted. After examining the Veteran, the examiner should provide an opinion as to whether the Veteran's atrial fibrillation, hypertension, and/or mitral valve insufficiency are at least as likely as not: a) related to or aggravated by service, b) caused, at least in part, by the Veteran's service-connected ischemic heart disease and/or PTSD with major depressive disorder (alone or in the aggregate), or c) aggravated, at least in part, by the Veteran's service-connected ischemic heart disease and/or PTSD with major depressive disorder, (alone or in the aggregate) or d) caused, at least in part, by the Veteran's Agent Orange exposure? The examiner should consider the Veteran's claim for chest pains one month after separation and diagnosis of hypertension in 1973, as well as the Veteran's lay statements regarding the onset of his symptoms. A complete rationale for any opinion expressed and conclusion reached should be set forth in the report 10. Schedule the Veteran for an appropriate VA examination to determine whether his claimed low back disorder is related to service. The examiner should review the claims file and note that review in the report. All appropriate tests and studies should be conducted. After examining the Veteran, the examiner should address the following: a) Diagnose all lumbar conditions from which the Veteran currently suffers. b) Provide an opinion as to whether the Veteran's current lumbar conditions are at least as likely as not related to service, including the low back pain and biconcave deformity of several lumbar vertebrae noted in the service treatment records. The examiner should consider the Veteran's back to have been sound at the time he entered service. The examiner should also consider the Veteran's lay statements regarding the onset and recurrence of his low back symptoms. A complete rationale for any opinion expressed and conclusion reached should be set forth in the report. 11. Then, readjudicate the Veteran's claims. If action remains adverse to the Veteran, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate opportunity to respond. Thereafter, return the case to the Board. 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). 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). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs