Citation Nr: 1327855 Decision Date: 08/30/13 Archive Date: 09/05/13 DOCKET NO. 06-22 555 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to an initial rating higher than 10 percent, prior to January 17, 2006 and from April 1, 2006, for a status-post left varicocelectomy, on a schedular and extraschedular basis. 2. Entitlement to service connection for an acquired psychiatric disorder, to include bipolar disorder, anxiety and depression. 3. Entitlement to service connection for a dental trauma to tooth number 10 for purposes of eligibility for dental treatment. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD Kristy L. Zadora, Counsel INTRODUCTION The Veteran had active duty service from February 1986 to June 1989. These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania which, in pertinent part, denied the Veteran's claims for service connection for bipolar disorder, depressive disorder and dental trauma with tooth loss. In addition, the Veteran's claim for service connection for a status-post left varicocelectomy was granted and an initial noncompensable rating was assigned. A review of the Virtual VA claims processing system reveals VA treatment records dated through November 2012; such records were considered by the Appeals Management Center (AMC) in a January 2013 supplemental statement of the case (SSOC). In March 2006, the Veteran testified before a Decision Review Officer (DRO) at a hearing at the RO. A hearing transcript has been associated with the claims file. In August 2010, the RO awarded a temporary total rating based upon surgical or other treatment necessitating convalescence for the Veteran's status-post left varicocelectomy for the period from January 17, 2006 to April 1, 2006. A 10 percent rating was also assigned for the appellate period prior to January 17, 2006 and following April 1, 2006. As this assigned rating is not the maximum ratings available for these disabilities, these claims remain in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). In March 2011, the Veteran testified before the undersigned Veterans Law Judge at a RO (Travel Board) hearing. A hearing transcript has been associated with the claims file. In June 2011, the Board denied the Veteran's claim for service connection for a dental trauma with tooth loss. The remaining claims for an increased rating for a status-post left varicocelectomy and for service connection for an acquired psychiatric disorder were remanded to the AMC for additional development and adjudication. The Veteran subsequently appealed the Board's June 2011 denial of the claim for service connection for a dental trauma with tooth loss to the United States Court of Appeals for Veterans Claims (Court). In a June 2011 Memorandum Decision, the Court vacated the Board's June 2011 decision as to this claim and remanded the matter to the Board for additional adjudication. As a final preliminary matter, the Board notes that it had previously recharacterized the instant claim for service connection for an acquired psychiatric disorder to include bipolar disorder, anxiety and depression so as to more accurately reflect the evidence of record and the Veteran's complaints of symptomatology as well as to comport with the holding in Clemons v. Shinseki, 23 Vet. App. 1 (2009). The issue of entitlement to an increased rating for a status-post left varicocelectomy is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. The evidence of record does not substantiate or establish the existence of a current anxiety disorder or depressive disorder. 2. Direct service connection for the Veteran's diagnosed alcohol dependence is prohibited under pertinent VA law and regulations. 3. The competent evidence shows that the Veteran's current acquired psychiatric disability, to include bipolar disorder and panic disorder, is not related to active service or any incident of service or that psychosis manifested to a compensable degree within one year of service discharge. 4. The Veteran sustained dental trauma to tooth 10 during service due to negligence or malpractice by the service department. CONCLUSIONS OF LAW 1. An acquired psychiatric disorder, to include bipolar disorder, anxiety and depression, was not incurred in or aggravated by the Veteran's active duty service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 2. Resolving all reasonable doubt in the Veteran's favor, the criteria are met for service connection for residuals of dental trauma to tooth 10 for purposes of receiving VA outpatient dental treatment (Class II eligibility). 38 U.S.C.A. §§ 1712, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.381, 4.150, 17.161 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist With respect to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the Court held that 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; and (3) that the claimant is expected to provide. The Court held in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), that the VA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include (1) the veteran's status; (2) the existence of a disability; (3) a connection between the veteran's service and the disability; (4) the degree of disability; and (5) the effective date of the disability. The Court held that, upon receipt of an application for a service connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim, and to provide the veteran with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id. at 486. This notice must also inform the veteran that a disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id. With respect to the Veteran's service connection for a dental trauma to tooth number 10, given the favorable disposition of the action here, which is not prejudicial to the Veteran, the Board need not assess VA's compliance with the VCAA. See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92, 57 Fed. Reg. 49,747 (1992). With respect to the claim for service connection for an acquired psychiatric disorder, the Veteran was provided letters in February 2002, September 2005 and March 2006 which fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, at 187. The letter issued in March 2006 also provided appropriate notice under Dingess/Hartman. After the issuance of these letters, and opportunity for the Veteran to respond, the November 2006 SSOC reflects readjudication of the claim. Hence, the Veteran is not shown to be prejudiced by the timing of the notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an statement of the case (SOC) or SSOC, is sufficient to cure a timing defect). In addition, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of any notice provided. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, falls upon the party attacking the agency's determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). All the law requires is that the duty to notify is satisfied and that claimants are given the opportunity to submit information and evidence in support of their claims. Once this has been accomplished, all due process concerns have been satisfied. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996); see also 38 C.F.R. § 20.1102 (harmless error). In view of the foregoing, the Board finds that the Veteran was notified and aware of the evidence needed to substantiate his claims, as well as the avenues through which he might obtain such evidence, and of the allocation of responsibilities between himself and VA in obtaining such evidence. Accordingly, there is no further duty to notify. The Board also concludes VA's duty to assist has been satisfied. The evidence of record includes the service treatment records, VA outpatient treatment records, various private treatment records, Social Security Administration (SSA) records and the VA examination reports. Additionally, the Veteran was afforded a VA examination in order to adjudicate his claim for service connection. In this regard, the Board notes that the August 2011 VA examiner offered an etiological opinion as to the claimed disorder and based his conclusions on the existing medical evidence and the other evidence of record. Moreover, such opinion offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); 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"). As such, the Board finds that the opinion proffered by the VA examiner is sufficient to assist VA in deciding the instant claim for service connection. Additionally, the Board finds there has been substantial compliance with its June 2011 remand directives. The Board notes that the Court has recently noted that "only substantial compliance with the terms of the Board's engagement letter would be required, not strict compliance." See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268) violation when the examiner made the ultimate determination required by the Board's remand.) The record indicates that the AMC scheduled the Veteran for a VA pyschological examination, which he attended, and a July 2011 letter requested that the Veteran complete a VA Form 21-4142 for each private health care provider who had treated him for his claimed disability. Based on the foregoing, the Board finds that the AMC substantially complied with the mandates of its remand. See Stegall, supra, (finding that a remand by the Board confers on the appellant the right to compliance with its remand orders). Therefore, in light of the foregoing, the Board will proceed to review and decide the claim. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. 3.103(c)(2) requires that any Veterans Law Judge who chairs a hearing fulfill two duties to comply with the VCAA. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant, 23 Vet. App. at 488. Here, during the March 2011 hearing, the undersigned Veterans Law Judge enumerated the issue on appeal. Also, information was solicited regarding the etiology of the Veteran's claimed psychiatric disorder, to include the Veteran's reports that his psychological problems had been continuous since service and that he began receiving psychiatric treatment after his first suicide attempt in 1992. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. Id. at 497. As such, the Board finds that, consistent with Bryant, the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claim based on the current record. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). The Veteran has submitted argument and evidence in support of the appeal. Based on the foregoing, the Board finds that the Veteran has had a meaningful opportunity to participate in the adjudication of his claim such that the essential fairness of the adjudication is not affected. II. Service Connection A. Applicable Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). In a recent decision, the United States Court of Appeals for the Federal Circuit (the Federal Circuit) determined that such an alternative method can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board notes that psychosis is listed as a chronic diseases under 38 C.F.R. §§ 3.307(a), 3.309(a). In relevant part, 38 U.S.C.A. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical profession." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence.") Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. B. Psychiatric Disorder The Veteran asserts that his in-service psychiatric symptoms were manifestations of his bipolar and anxiety disorders, despite not being diagnosed as such during service. Service treatment records indicate that the Veteran had presented for treatment after his fellow crewmembers noticed that he was "very upset" and had "stayed up crying most of the previous night" in January 1989. He reported anxiety and sadness related to his health situation and an Axis I diagnosis of a "life circumstance problem" was made. A February 1989 service discharge examination found the Veteran to be normal psychologically and was negative for other relevant abnormalities. The Veteran denied nervous trouble of any sort or depression in an accompanying Report of Medical History (RMH). Post-service clinical records indicate that the Veteran underwent in-patient psychiatric treatment in November 1992, January 1996 and February 1996 and that he was diagnosed with a psychiatric disorder, namely major depression, in November 1992. Other diagnosed disabilities included bipolar disorder, diagnosed in November 2000 and panic-anxiety disorder, diagnosed in August 2002. A September 2003 statement from the Veteran's mother described the Veteran's personality changes during service. She also stated that "he wasn't the same person" when he returned home after discharge. During a March 2006 hearing, the Veteran testified that he attempted suicide in 1991 and was then admitted to a psychiatric unit. During a March 2011 hearing, the Veteran testified that he was first diagnosed with bipolar disorder in 1995 but that he had continuously experienced psychiatric symptoms since service. In an August 2011 report, the VA examiner opined that the Veteran's bipolar disorder was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness as it was first shown in the Veteran's medical records in 1997 and he had been treated for repeated episodes of major depression and suicidal behavior since November 1992. The examiner noted the Veteran's statements that he had experienced such symptoms as suicidal ideations and racing thoughts dating back to 1989 but that he did not seek treatment for such symptoms; however, even in taking the Veteran's lay statements into account, the symptoms did not reach clinical significant (necessary for the diagnosis of any of the mental disorders) until 1991 at the earliest in the examiner's opinion. In addition, the examiner noted that the Veteran's in-service psychiatric examinations were normal, that he checked "no" for symptoms relating to mental distress on symptom checklist at service discharge and the only in-service notation of emotional distress was when he was seen for a mental health consultation for distress the day after he admitted to being homosexual, which he knew meant that he would likely be discharged from service. This emotional reaction was judged to be appropriate given the stressor and the Veteran's mother's statement that the Veteran had a depressed mood just after service discharge would be consistent with an appropriate emotional reaction to the loss of his military career in the examiner's opinion. The examiner further noted that the remainder of the Veteran's mother's statement makes it clear that that the symptoms of the clinical psychiatric disorder were not present until at least 1992. The August 2011 VA examiner further opined that the Veteran's panic disorder was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness as panic symptoms were first shown in the clinical evidence in March 1996 and listed as a diagnosis in 2002. The examiner noted that the Veteran's service records include complaints of anxiety, which was not consistent with panic, but rather consistent with situational stressors, and the emotional reaction was judged to be appropriate given the stressor. In addition, the examiner further noted that the Veteran's mother described panic symptoms in her statement but it is not clear when these symptoms developed and the medical records indicate that symptoms of a clinical psychiatric disorder were not present until at least 1992. As an initial matter, the Board finds that the Veteran has a current diagnosis of an acquired psychiatric disorder, namely bipolar disorder and panic disorder with agoraphobia. While he has also generally claimed service connection for anxiety and depression, such an anxiety disorder or depressive disorder have not been diagnosed at any time during the appeal period. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (the requirement that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even if the disability resolves prior to the adjudication of the claim). In addition, while there are notations in some of the clinical records suggesting that the Veteran suffered from anxiety and depression, such notations were based on the Veteran's subjective reports rather than objective clinical findings and do not constitute a diagnosis of anxiety. Notwithstanding the Veteran's documented in-service complaints of anxiety and sadness and the diagnosis of a "life circumstances problem," the Veteran's service discharge examination reflects that he was normal psychiatrically. With respect to post-service medical records, the first evidence of a psychiatric disorder was in a November 1992 private treatment note. As noted above, there is nothing in the Veteran's service records to indicate that a psychiatric disorder, to include bipolar disorder and depressive disorder, had its onset during service or shortly after service. Rather, the first clinical evidence of such an acquired psychiatric disorder was in 1992, approximately three years after the Veteran separated from service. The Board points out that the passage of years between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). Moreover, the probative evidence of record fails to demonstrate that the Veteran's acquired psychiatric disorder, to include bipolar disorder and panic disorder, are related to his service. In this regard, the Board places great probative weight on the VA examiner's opinion that the Veteran's acquired psychiatric disorder was less likely than not related to his service as he developed such a disorder more than three years after service and that his in-service complaints of anxiety and sadness were judged to be appropriate to his in-service stressor. This examiner's opinion had clear conclusions and supporting data, as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. Accordingly, as the probative evidence of records demonstrates that the current acquired psychiatric disorder are not related to service, service connection is not warranted. The Board notes that the Veteran has, on occasion, alleged a continuity of symptomology with regards to his psychiatric disorder, which he is competent to assert. However, he has not been consistent in his assertions regarding the onset and presence of such a disorder. In a November 1992 private treatment note, which contained the first post-service clinical evidence of a psychiatric disorder, the Veteran denied a history of psychiatric problems or that he had seen a psychiatrist. He later reported a two year history of a mood disorder in a May 1999 private treatment note. Although he indicated that his anxiety and bipolar symptoms began in 1989 in his January 2002 VA Application for Compensation or Pension (VA Form 21-526), he denied nervous trouble of any sort or depression in a February 1989 RMH. The Board, therefore, accords the Veteran's statements regarding the onset of his psychiatric symptoms prior to the filing of the instant claim more probative weight than any such report of symptoms made in connection with, or, presumed by the filing of, the Veteran's January 2002 claim for service connection. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) (a pecuniary interest may affect the credibility of a claimant's testimony). Moreover, in light of the contradictory statements regarding the onset of his current psychiatric disorder or symptoms related to this disorder, any current assertions as to experiencing psychiatric symptoms continuously since service, advanced in furtherance of the appeal, are deemed not credible. Furthermore, as for any direct assertions by the Veteran and/or his representative that there exists a medical relationship between the Veteran's acquired psychiatric disorder and service, the Board finds that no such assertions provide persuasive evidence in support of the claim. The matter of the etiology of the disability here at issue is one within the province of trained professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). As none of the identified individuals is shown to be other than a layperson without the appropriate training and expertise, neither is competent to render a probative (i.e., persuasive) opinion the medical matter upon which this claim turns. See, e.g., Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ('a layperson is generally not capable of opining on matters requiring medical knowledge'). Hence, the lay assertions of medical nexus have no probative value. Moreover, a psychiatric disorder, to include bipolar disorder and a panic disorder, may not be presumed to have been incurred during service here as they did not manifest to a compensable degree within one year of separation from active duty. Finally, with regards to the Veteran's diagnosed alcohol dependence, the Board notes that service connection for a primary disability caused by alcoholism is prohibited for all service connection claims filed after October 1, 1990, as in this case. See 38 U.S.C.A. §§ 105, 1110; 38 C.F.R. §§ 3.1(n), 3.301(d); see also Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001) (noting that 38 U.S.C.A. § 1110 precludes compensation for primary alcohol abuse disabilities and for secondary disabilities that result from primary alcohol abuse). To the extent that the Veteran's service connection claim for an acquired psychiatric disability is based on his assertion that alcoholism caused or contributed to this disability, it must be denied as a matter of law. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). For all the foregoing reasons, the claim for service connection for a psychiatric disorder, to include bipolar disorder, anxiety and depression, must be denied. In reaching the conclusion to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). C. Dental Trauma The Veteran contends he underwent an unnecessary bridge replacement during service, resulting in a fracture and the eventual removal of tooth number 10. Disability compensation and VA outpatient dental treatment may be provided for certain specified types of service-connected dental disorders. For other types of service-connected dental disorders, the claimant may receive treatment only and not compensation. 38 U.S.C.A. § 1712; 38 C.F.R. §§ 3.381, 4.150, 17.161. Disability compensation may be provided for certain specified types of service-connected dental disorders (Class I). See 38 C.F.R. § 17.161(a). There is no time limitation for making application for treatment and no restriction as to the number of repeat episodes of treatment. The types of dental disorders that may be compensable include irreplaceable missing teeth and disease or damage to the jaw. 38 C.F.R. § 4.150, Diagnostic Codes 9900-16. Those having a service-connected noncompensable dental condition or disability may be authorized any treatment as reasonably necessary for the correction of such service-connected dental condition or disability (Class II). See 38 C.F.R. § 17.161(d). Certain dental conditions, including periodontal disease, treatable carious teeth, and replaceable missing teeth (i.e. with a bridge or denture), are not considered disabling and may be service connected solely for the purpose of determining entitlement to VA dental examination or outpatient dental treatment under the provisions of 38 C.F.R. §§ 17.120 or 17.123, but not for purposes of compensation. The Board notes that in essence, the significance of a finding that a noncompensable service-connected dental condition is due to dental trauma, as opposed to other causes, is that VA provides any reasonably necessary dental treatment, without time limitations, for conditions which are attributable to the service trauma, whereas other service-connected noncompensable dental conditions are typically subject to limitations of one-time treatment and timely application after service. 38 U.S.C.A. § 1712; 38 C.F.R. § 17.161. The Veteran asserts that during boot camp, unnecessary dental work was completed by his service department, causing dental problems and pain. He further asserts that the service department's dental treatment was negligently performed and hence constitutes dental trauma for VA purposes. In addition, the Board notes that during his March 2011 hearing, the Veteran limited his claim to eligibility for dental treatment only. See Hamilton v. Brown, 4 Vet. App. 528 (1993) (holding that where a claimant expressly indicates an intent that adjudication of certain specific claims not proceed at a certain point in time, neither the RO nor the Board has authority to adjudicate those specific claims). Service treatment records indicate that the Veteran's dental entrance examination was found to be acceptable in September 1985. In February 1986, the cantilever of teeth 9 and 10 were evaluated, and a provisional bridge was placed but not completed. The provisional bridge dislodged due to caries and endodontics was performed on tooth 10 in March 1987. An additional provisional cantilever bridge was placed. A fracture of tooth 10 later occurred and it was extracted. An August 2002 VA dental examiner, following a review of the Veteran's claims file and a physical examination, opined that the missing tooth 10 was due to a nonrestorable fracture that occurred after endodontic treatment of that tooth. The examiner noted that the service department was "trying to improve on what was present, violating the rule of [i]f it ain't broke don't fix it" and that tooth 10 may be considered "service-connected due to unnecessary dental treatment." On review, the Board concludes that the Veteran is entitled to Class II outpatient dental treatment. As detailed above, the Veteran maintains that the dental trauma suffered during service was the unnecessary dental treatment performed by his service department which resulted in the removal of tooth 10. Thus, the dispositive question is whether the removal of tooth 10 constitutes 'service trauma' as contemplated by the controlling regulations and case law. Pertaining to dental compensation claims, the United States Court of Appeals for the Federal Circuit (Federal Circuit) defined "service trauma" as "an injury or wound produced by an external force during the service member's performance of military duties." See Nielson v. Shinseki, 607 F.3d 802, 808 (Fed. Cir. 2010). The definition excluded "the intended result of proper medical treatment." Id. However, in Nieslon, the Federal Circuit specifically noted, "[w]e do not, however, suggest that an unintended result of medical treatment due to military negligence or malpractice could not be a 'service trauma'..." Id. Thus, in light of the Veteran's competent and credible statements of in-service injury, the holding in Nielson, the findings of the August 2002 VA examiner and with resolution of any doubt in the Veteran's favor, the Board finds that the evidence establishes that removal of tooth 10 during service was a service trauma, i.e. due to service department negligence or malpractice, and that Class II eligibility for dental treatment is warranted. Resolving reasonable doubt in favor of the Veteran, any treatment indicated as reasonably necessary for the correction of this service-connected noncompensable condition or disability may be authorized. See 38 C.F.R. § 17.161(c); see also Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (indicating an "absolutely accurate" determination of etiology is not a condition precedent to granting service connection, nor is "definite" or "obvious" etiology). ORDER Service connection for an acquired psychiatric disorder, to include bipolar disorder, anxiety and depression, is denied. Service connection for residuals of dental trauma to tooth 10, for purposes of receiving Class II VA outpatient dental treatment, is granted. REMAND The Board is cognizant of the fact that the Veteran's claim for a compensable rating for status-post left varicocelectomy has been remanded in the past. Consequently, the Board wishes to assure the Veteran that it would not be remanding the claim again unless it was essential for a full and fair adjudication. The Veteran's status-post left varicocelectomy is currently rated by analogy under the Diagnostic Codes for an unlisted genitourinary condition and for chronic epididymo-orchitis, which is to be rated as a urinary tract infection. The Veteran has argued that he does not suffer from urinary tract infections and that his disability is more appropriately rated as a voiding dysfunction, which would entitle him to at least a 40 percent rating. A January 2013 VA genitourinary examination noted that the Veteran underwent a left orchiectomy due to chronic pain from the varicocle as well as his voiding dysfunction but attributed such voiding symptoms to his benign prostatic hypertrophy (BPH). However, it is not clear whether the Veteran's BPH is related to, or a manifestation of, his service-connected status-post left varicoclectomy. Such clarification should be obtained on remand. Accordingly, the case is REMANDED for the following action: 1. Obtain an addendum to the January 2013 VA genitourinary examination, if possible, or afford the Veteran a VA examination to determine the severity of his service-connected status-post left varicocelectomy. The examiner should review the claims folder and note such review in the examination report. The examination should include a review of the Veteran's history and current complaints as well as a comprehensive evaluation and any tests deemed necessary. The examiner is asked to furnish an opinion with respect to the following questions: What is the relationship, if any, between the Veteran's service-connected status-post left varicocelectomy and his benign prostatic hypertrophy? Is his voiding dysfunction a manifestation of, or attributable to, his service-connected status-post left varicocelectomy? If so, what is the current severity of his voiding dysfunction? In answering the above questions, the examiner is asked to consider the Veteran's assertion that his voiding dysfunction is a manifestation of his service-connected status-post left varicocelectomy. A complete rating should be given for each opinion expressed. In this regard, a discussion of the facts and medical principles involved would be considerable assistance to the Board. 2. If the benefit sought on appeal remains denied, a supplemental statement of the case should be issued, before the claims file is returned to the Board, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter 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 (CONTINUED ON NEXT PAGE) 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). ______________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs