Citation Nr: 1327890 Decision Date: 08/30/13 Archive Date: 09/05/13 DOCKET NO. 08-36 698 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a disability manifested by dizziness/episodes of passing out. 2. Entitlement to service connection for a liver disability, to include claimed cirrhosis, claimed as due to herbicide exposure. 3. Entitlement to service connection for an enlarged heart, claimed as due to herbicide exposure. 4. Entitlement to service connection for erectile dysfunction, claimed as secondary to service-connected diabetes mellitus. 5. Entitlement to a permanent and total rating for non-service-connected pension purposes. ATTORNEY FOR THE BOARD T. Sherrard, Counsel INTRODUCTION The Veteran had active service from September 1969 to August 1971. This matter comes before the Board of Veterans' Appeals (BVA or Board) from an August 2009 rating decision by the above Department of Veterans Affairs (VA) Regional Office (RO). The Board has not only reviewed the Veteran's physical claims file, but also the electronic file on the "Virtual VA" system, to ensure a total review of the evidence in this case. In July 2011, the Board adjudicated a number of issues and remanded the issues listed on the first page of this decision for further development. The previously remanded the issues of service connection for dizziness and episodes of passing out and cirrhosis of the liver are recharacterized as service connection for a disability manifested by dizziness and episodes of passing out and service connection for a liver disorder, claimed as due to herbicide exposure, as shown on the first page of this decision to reflect more accurately the scope of the claims. See generally Clemons v. Shinseki, 23 Vet. App. 1 (2009). Notably, while the case was in remand status, the previously remanded service connection claim for hiatal hernia was granted; therefore, it is no longer before the Board. In its July 2011 decision, the Board referred the issue of entitlement to an earlier effective date for the grant of service connection for posttraumatic stress disorder (PTSD) to the Agency of Original Jurisdiction (AOJ) for appropriate action. See July 2010 statement received by the Board, page 4. However, it does not appear that the AOJ has had the opportunity to act upon that claim. Therefore, the Board does not have jurisdiction over it, and it is again referred to the AOJ for appropriate action. The issues of: 1) service connection for a disability manifested by dizziness and passing out; 2) service connection for erectile dysfunction; and 3) entitlement to a permanent and total rating for non-service-connected pension purposes 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. FINDINGS OF FACT 1. The Veteran had qualifying service in Vietnam; therefore, exposure to herbicide agents is presumed. 2. The Veteran is currently diagnosed with nonalcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH). 3. The currently diagnosed liver disability is not listed as a disease presumptively associated with herbicide exposure, did not manifest for many years after service separation, is not otherwise causally or etiologically related to service, to include exposure to herbicide agents, and was not caused or aggravated by a service-connected disability. 4. The Veteran does not currently suffer from a heart disability, to include an enlarged heart. CONCLUSIONS OF LAW 1. The criteria for service connection for a liver disability have not been met, to include on a presumptive basis. 38 U.S.C.A. §§ 101, 1101, 1110, 1112, 1113, 1116, 1137, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 2. The criteria for service connection for an enlarged heart have not been met, to include on a presumptive basis. 38 U.S.C.A. §§ 101, 1101, 1110, 1112, 1113, 1116, 1137, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connections Law and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Cardiovascular disease is a "chronic disease" listed under 38 C.F.R. § 3.309(a); however, the Veteran is not currently diagnosed with a heart disability, as explained below. The Veteran's currently diagnosed liver disability (i.e., NAFLD/NASH) is not a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on "chronic" symptoms in service and "continuous" symptoms since service are not applicable. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In certain cases, service connection can be presumed if a veteran was exposed to an herbicide agent during active service. Under the current Code of Federal Regulations (C.F.R.), presumptive service connection is warranted for the following disorders: AL amyloidosis; chloracne or other acneform disease consistent with chloracne; Type II diabetes; Hodgkin's disease; chronic lymphocytic leukemia; multiple myeloma; non-Hodgkin's lymphoma; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx, or trachea); ischemic heart disease; Parkinson's disease; hairy cell leukemia; and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e) (2012). Presumptive service connection for these disorders as a result of Agent Orange exposure is warranted if the requirements of 38 C.F.R. § 3.307(a)(6) are met. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.309(e). The governing law provides that a "veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent . . . unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service." 38 U.S.C.A. § 1116(f). Pursuant to Section 3 of the Agent Orange Act of 1991, Pub. L. No. 102-4, 105 Stat. 11, the Secretary of Veterans Affairs (Secretary) entered into an agreement with the National Academy of Sciences (NAS) to review and summarize the scientific evidence concerning the association between exposure to herbicides used in Vietnam and various diseases suspected to be associated with such exposure. The NAS was to determine, to the extent possible, whether there was a statistical association between the suspect disease and herbicide exposure, taking into account the strength of the scientific evidence and the appropriateness of the methods used to detect the association; the increased risk of disease among individuals exposed to herbicides during the service in the Republic of Vietnam during the Vietnam era; and whether there is a plausible biological mechanism or other evidence of a causal relationship between herbicide exposure and the suspect disease. The NAS was required to submit reports of its activities every two years. The Secretary, under the authority of the Agent Orange Act of 1991 and based on studies by the NAS, has determined that there is no positive association between exposure to herbicides and any condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-346 (1994); see also Notice, 61 Fed. Reg. 41,442-449, and 61 Fed. Reg. 57,586-589 (1996); Notice, 64 Fed. Reg. 59,232-243 (Nov. 2, 1999); Notice, 67 Fed. Reg. 42,600-608 (June 24, 2002); Notice, 72 Fed. Reg. 32,395-407 (June 12, 2007); 74 Fed. Reg. 21,258-260 (May 7, 2009). When a disease is first diagnosed after service but not within an applicable presumptive period, service connection may nevertheless be established by evidence demonstrating that disease was in fact incurred during service. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). If there is no presumptive service connection available, direct service connection can be established if the record contains competent medical evidence of a current disease process with a relationship to exposure to an herbicide agent while in military service. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303; Combee at 1043-44. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." See Layno, 6 Vet. App. at 469; 38 C.F.R. § 3.159(a)(2). The Court has emphasized that when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of a veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service Connection for a Liver Disability The Veteran contends that he currently has a liver disability, claimed as cirrhosis of the liver, due to herbicide exposure during active service. The service personnel records confirm that he served in Vietnam from September 1970 to August 1971; therefore, exposure to herbicide agents is presumed. 38 U.S.C.A. § 1116(f). There is ample evidence of record showing a current liver disability. At the VA medical examinations performed in connection with the appeal, the Veteran was diagnosed with nonalcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH). Notably, the Veteran is not shown to have been diagnosed with cirrhosis of the liver. Because the Veteran's currently diagnosed liver disability is not listed among the Agent Orange-related diseases enumerated in 38 C.F.R. § 3.309(e), medical nexus may not be presumed as a matter of law. Notwithstanding the inapplicability of the Agent Orange presumptive service connection regulations, the Board is obligated to fully consider the Veteran's service connection claim on a direct basis. See Combee, 34 F.3d at 1043-1044. After a review of all the evidence of record, lay and medical, the Board finds that the weight of the evidence demonstrates that the Veteran did not sustain a relevant event, injury, or disease of the liver during active service. Indeed, service treatment records do not demonstrate complaints, findings, diagnosis, or treatment of a liver problem. The August 1971 separation examination report is negative for any complaints or symptoms of a liver disability, and clinical evaluation of all systems is marked as normal. Next, the Board finds that the weight of the evidence demonstrates that symptoms of the currently diagnosed liver disability did not manifest until many years after service. As discussed above, the service treatment records are absent of any complaint, finding, or treatment for liver problems, and no symptoms of a liver disability were reported or detected at the August 1971 separation examination. Also, after service, the Veteran filed service connection claims with VA for other disabilities in September 1971, March 1989, and October 1999; however, he made no mention of a liver problem. In fact, post-service treatment records do not show treatment or report of a liver problem until 2006, when VA treatment records show that a CT scan of the abdomen revealed fatty infiltration of the liver, but no focal liver abnormality. Notably, the prior November 1971 and July 1989 VA examination reports are absent of any findings or diagnosis of a liver problem, and a March 2005 VA treatment note indicates a normal hepatic examination. The absence of any post-service history, complaints, symptoms, diagnosis, or treatment of a liver problem until 35 years after service is evidence against the claim. See Buchanan, 451 F.3d at 1336 (Fed. Cir. 2006) (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible). The Board further notes that the weight of the evidence is against finding that the Veteran's current liver disability, which first manifested many years after service separation, is causally or etiologically related to service or a service-connected disability. Pursuant to the Board's remand order, the Veteran was afforded a VA examination in January 2013 and diagnosed with NAFLD at that time. After review of the record and examination of the Veteran, the VA examiner opined that it was unlikely (i.e., as defined in the Board Remand order, a less than 50 percent probability) that the Veteran's NAFLD was secondary to herbicide exposure or secondary to or aggravated by service-connected diabetes, ulcer, or PTSD. In support of the conclusion, the VA examiner noted that the Veteran had been diagnosed with fatty infiltration of the liver in May 2006, which was an incidental finding on a CT scan of the abdomen, and medication was not required for control of the Veteran's liver condition. The VA examiner noted that the Veteran did not have any signs or symptoms attributable to chronic or infectious liver diseases, including cirrhosis. The VA examiner stated that there was no current diagnosis of cirrhosis. The VA examiner then opined that the Veteran most likely had nonalcoholic fatty liver disease (NAFLD), which is most commonly associated with metabolic syndrome, according to medical literature. Further, the examiner stated that the medical literature did not support the contention that NAFLD is associated with exposure to herbicides. The 2013 VA medical opinion is factually accurate, and is supported by an adequate rationale. The VA examiner was informed of the pertinent evidence, reviewed the claims file, conducted a thorough physical examination and interview of the Veteran, and fully articulated the opinion. There is no competent medical opinion to the contrary of record. For these reasons, it is of great probative value. Based on the evidence of record, the weight of the competent evidence demonstrates no relationship between the Veteran's currently diagnosed liver disability and his military service. The service treatment records show no evidence of a liver disability, and the first evidence of a liver disability is not until many years after service separation. The Veteran's liver disability has not been competently linked to service, to include presumed herbicide exposure, or a service-connected disability. The Veteran is a lay person and is not competent to diagnose the liver disability or attribute any symptoms he experiences to a diagnosed liver disability. To the extent that the Veteran may have suggested that he has experienced liver problems since service, the Board does not find the assertion to be credible in light of the absence of any complaints or findings of a liver disability during service and for many years after service separation, the failure to file a claim for a liver disability when filing other claims with VA for disability compensation in the years following service separation, and the negative VA medical opinion. This evidence outweighs the Veteran's more recent contentions because the evidence was generated closer in time to the Veteran's period of active service. Therefore, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection for a liver disability, and service connection must be denied. As the preponderance of the evidence weighs against the Veteran's claim, the benefit of the doubt doctrine is not applicable, and the claim for service connection must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Service Connection for Enlarged Heart The Veteran contends that he has an enlarged heart due to herbicide exposure during active service. As stated above, exposure to herbicide agents is presumed based on the Veteran's Vietnam service. 38 U.S.C.A. § 1116(f). After a review of all the evidence of record, lay and medical, the Board finds that the weight of the evidence demonstrates that the Veteran did not sustain a relevant event, injury, or disease of the heart during active service and did not experience chronic symptoms in service. Service treatment records do not demonstrate complaints, findings, diagnosis, or treatment of a heart problem. The August 1971 separation examination report is negative for any reports or complaints of symptoms of a heart disability, and clinical evaluation of the heart is marked as normal. Next, the Board finds that the weight of the evidence demonstrates that there was no indication of a heart disability until many years after service separation. The August 1971 service separation examination report, as discussed above, is negative for any symptoms, findings, or diagnosis of a heart problem. Post-service medical records do not identify any treatment or report of a heart problem until 2006, when VA treatment records show that a CT scan of the abdomen revealed an enlarged heart. The Veteran has not contended that his heart problem began during active service. However, to the extent that his contentions made in the context of the current claim can be interpreted as an assertion that symptoms of a heart problem began in service and that his symptoms have continued while in service and following service, the Board finds that, while the Veteran is competent to report the onset of symptoms of heart problems, his recent report of continuous symptoms since service is outweighed by the other, more contemporaneous, lay and medical evidence of record, both in service and after service, and is not credible. See Charles, 16 Vet. App. 370. The Board finds that the Veteran's statements as to chronic heart symptoms in service and continuous heart symptoms since service are not accurate because they are outweighed by other evidence of record that includes the absence of in-service complaints or symptoms of heart problems, the absence of any post-service history, complaints, symptoms, diagnosis, or treatment of a heart problem for 35 years after service, and the Veteran's claims for service connection for other disabilities in September 1971, March 1989, and October 1999 with no mention of a heart problem. As above, the Board acknowledges that symptoms, not treatment, are the essence of any evidence of continuity of symptomatology (Savage, 10 Vet. App. at 496); however, here, the Veteran filed multiple claims for service connection in September 1971, March 1989, and October 1999, but did not mention any symptoms of a heart problem at that time. This suggests to the Board that there was no pertinent heart symptomatology at that time. While inaction regarding filing a claim is not necessarily indicative of the absence of symptomatology, where, as here, a veteran takes action regarding other claims, it becomes reasonable to expect that the Veteran is presenting all issues for which he is experiencing symptoms that he believes are related to service. The Veteran demonstrated that he understood the procedure for filing a claim for VA disability compensation, and he followed that procedure in other instances where he believed he was entitled to those benefits. In such circumstances, it is more reasonable to expect a complete reporting than for certain symptomatology to be omitted. Thus, the Veteran's inaction regarding a claim for a heart disability, to include an enlarged heart, when viewed in the context of his action regarding other claims for compensation, may reasonably be interpreted as indicative of the Veteran's belief that he did not sustain a disability manifesting a heart problem in service, or the lack of heart symptomatology at the time he filed the claims, or both. In weighing the Veteran's statements of continuous symptomatology since service made in conjunction with the current claim for VA compensation against the lack of continuity of symptomatology in the record from 1971 to 2006, the Board finds that the absence of contemporaneous medical evidence of continuity of symptomatology for 35 years is also one additional factor, along with other lay and medical evidence stated above, that the Board has considered in finding that the Veteran's recent statements of continuity are less probative than the other evidence of record on the question of continuity of symptomatology after service. See Buchanan, 451 F.3d at 1336 (Fed. Cir. 2006) (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible). Additional evidence demonstrating that heart symptoms have not been continuous since service separation in August 1971 includes the November 1971 and July 1989 VA examination reports that are negative for any report, findings, or diagnosis of a cardiovascular problem, and VA treatment notes from March 2000, May 2009, and October 2010 VA treatment notes that show normal cardiovascular examination. The Board further finds that the weight of the evidence demonstrates that the Veteran does not have a current heart disability causally or etiologically related to service or a service-connected disability. When the Veteran underwent the January 2013 VA medical examination pursuant to the Board's remand order, the VA examiner noted that the Veteran had never been diagnosed with a heart condition, did not require medication, and had never had a myocardial infarction or congestive heart failure. The VA examiner also noted that the Veteran had never had an arrhythmia, heart valve condition, infectious heart conditions, or pericardial adhesions. The VA examiner further noted that the Veteran had never had cardiovascular surgery or been hospitalized for a heart condition. Additionally, the January 2013 VA examination report reveals that the cardiovascular examination was normal, and the VA examiner noted a normal EKG study conducted in May 2011. The METs test was normal. The VA examiner then commented that the only evidence of a cardiac abnormality was the incidental finding on the 2006 CT scan of the abdomen of an enlarged heart. The VA examiner noted that this finding had not been confirmed by other diagnostic testing. The VA examiner further stated that the "enlarged heart" was most likely due to hypertension, and that the Veteran's service-connected diabetes and duodenal ulcer were unlikely to cause the condition. Finally, the VA examiner wrote that herbicide exposure was not a recognized risk factor for the development of an enlarged heart. The 2013 VA medical opinion is competent and probative medical evidence because it is factually accurate, and is supported by an adequate rationale. The VA examiner was informed of the pertinent evidence, reviewed the claims file, conducted a thorough physical examination and interview of the Veteran, and fully articulated the opinion. There is no competent medical opinion to the contrary. Further, the Board notes that the VA examiner's opinion that the Veteran does not have a current disability of the heart is supported by other medical evidence of record. For example, a May 2011 VA treatment note indicates that the Veteran underwent an echocardiogram outside of VA in December 2010 showing left ventricular hypertrophy, no valve abnormalities, and mild diastolic dysfunction; however, the results were not attributed to a heart disability. For these reasons, the 2013 VA medical opinion is of great probative value. VA does not generally grant service connection for symptoms alone, without an identified basis for those symptoms. The VA needs to identify a disability, not symptoms of a disability, in order to grant service connection. In light of the 2013 VA medical opinion and lack of any post-service documentation of a diagnosis of a cardiovascular disability, the weight of the probative evidence is against finding that the Veteran has a current disability of the heart, to include an enlarged heart. As a result, the claim for an enlarged heart must be denied. Indeed, in the absence of proof of a present disability there can be no valid claim. Brammer at 225. The Board recognizes that the Court has held that the presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. See McClain. However, where the overall record fails to support a current diagnosis of the claimed disability, as is the case here, that holding would not apply. For these reasons, service connection for an enlarged heart must be denied. As the preponderance of the evidence weighs against the Veteran's claim for service connection for an enlarged heart, the benefit of the doubt doctrine is not applicable, and the claim for service connection must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The Court issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the 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, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In a April 2009 notice letter sent prior to the initial denial of the claims, the RO advised the Veteran regarding what information and evidence is needed to substantiate a claim for service connection, what information and evidence must be submitted by the Veteran, and what information or evidence VA will attempt to obtain. The RO also described how VA determines disability ratings and effective dates once service connection has been established. Therefore, the April 2009 notice letter fully satisfied VCAA notice requirements. VA has also made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the record includes the Veteran's service treatment records, service personnel records, post-service VA and private treatment records, VA medical opinions, and the Veteran's statements. The VA medical opinions were obtained in October 2012, January 2013, and March 2013 pursuant to the Board remand to address the question of whether the Veteran had a current disorder manifested by a liver disorder or an enlarged heart that was related to active service or service-connected disability. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA medical opinions obtained in this case are adequate as to the question of whether the Veteran has a liver disability related to active service or a service-connected disability, as well as whether the Veteran has a current heart disability. The VA medical opinions were predicated on a full reading of the private and VA medical records in the record, as well as a contemporaneous physical examination of the Veteran. The VA medical opinions considered all of the pertinent evidence of record, to include VA treatment records, comprehensive physical examinations, and the statements of the Veteran, and provide a complete rationale for the opinions stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the service connection claims decided herein has been met. 38 C.F.R. § 3.159(c)(4). Notably, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Pursuant to the Board's July 2011 remand order, updated VA treatment records were obtained, and the Veteran was provided with VA medical examination with a medical opinion in January 2013. The January 2013 VA medical examiners had adequate data on which to base the medical opinions and provided adequate rationale for the medical opinions. Thereafter, the claims decided herein were readjudicated. Therefore, there has been compliance with the Board's prior remand. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim adjudicated herein. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER Service connection for a liver disability is denied. Service connection for an enlarged heart is denied. REMAND Service connection for a disability manifested by dizziness/passing out In July 2011, the Board remanded the service connection claim for a disability manifested by dizziness and passing out, in pertinent part, to provide the Veteran with a VA medical examination to identify the appropriate diagnosis for the disorder and provide a medical opinion on whether the liver disorder initially manifested during or was caused by active service, to include an event or incident therein including presumed herbicide exposure, or caused or aggravated by service-connected diabetes mellitus or the service-connected gastrointestinal disability. In October 2012, the Veteran underwent VA medical examination, and the VA medical examiner noted that the Veteran's symptoms suggested postural hypotension (rather than vestibular dysfunction); however, the VA medical examination report is inadequate because the VA medical examiner provided no medical opinion on whether the Veteran's symptoms of dizziness and passing out during service were causally or etiologically related to the current postural hypotension or whether postural hypotension was caused or aggravated by the Veteran's service-connected diabetes mellitus or gastrointestinal disability. The Board directed that such opinions be provided in the prior remand order. For these reasons, the Board finds that a remand for a supplemental medical opinion is warranted. See Stegall v. West, 11 Vet. App. 268 (1998). Service connection for erectile dysfunction The Veteran contends that his current erectile dysfunction was either caused or aggravated by his service-connected diabetes mellitus. Although he has been afforded a VA examination with a medical opinion pursuant to the Board's prior remand order, the Board finds that the January 2013 VA examination is inadequate. Specifically, the VA examiner cited to medical literature that lists diabetes mellitus among multiple predictors for erectile dysfunction and stated that the Veteran had multiple risk factors for erectile dysfunction; however, he then stated that the Veteran's age was the most important etiologic factor for erectile dysfunction without providing sufficient rationale as to why the service-connected diabetes mellitus was not considered a causative factor for the Veteran's ED. Additionally, the VA examiner did not provide a medical opinion on whether the Veteran's erectile dysfunction has been aggravated by the service-connected diabetes mellitus, as ordered by the Board remand. Therefore, the Board finds that a remand for a supplemental medical opinion is necessary. See Stegall v. West, 11 Vet. App. 268 (1998). Permanent and total rating for non-service-connected pension purposes Regarding the claim for pension, subject to certain income and estate limitations, pension is payable to a Veteran who has served for 90 days or more during a period of war and who is permanently and totally disabled from nonservice-connected disability which is not the result of his own willful misconduct. 38 U.S.C.A. §§ 1502, 1521; 38 C.F.R. §§ 3.2(f), 3.23, 3.3. In this case, the Veteran satisfies the requirement of serving during a period of war, the Vietnam War era. Moreover, there is no current evidence that his income or assets render him ineligible for pension benefits. Accordingly, the issue of entitlement to VA pension appears to turn on whether he is permanently and totally disabled as a result of nonservice-connected disabilities that were not the result of his own willful misconduct. In order to properly to make this determination, the Board finds that further development is necessary in this matter. In this case, the RO has denied the Veteran's claim on the basis that there is evidence showing that he is able to work. However, a December 2012 VA allergy and immunology consult note reads that the Veteran is "disabled" for his work history. Therefore, it is unclear from the current record whether the Veteran is unemployable due to disability. Accordingly, the case is REMANDED for the following actions: 1. Obtain a supplemental medical opinion from an appropriate medical professional, addressing the etiology of the Veteran's current disability manifested by dizziness and episodes of passing out. If another medical examination is necessary in order to provide the requested medical opinion, please so schedule. The relevant documents from the record should be provided to the VA examiner for review. The examiner should confirm review of the record in the examination report. Based on review of the appropriate records, the examiner should offer opinions on the following questions: a) Is it as likely as not (i.e., to a probability of 50 percent or greater) that the Veteran's disability manifested by dizziness and passing out had its onset during service or is otherwise causally or etiologically related to service, to include consideration of the symptomatology shown therein or presumed in-service herbicide exposure? Please specify the current diagnosis for the disability manifested by dizziness and passing out and consider the reported symptomatology during service (i.e., in May 1971). Please explain the basis for the opinion. b) Is it as likely as not (i.e., to a probability of 50 percent or greater) that the Veteran's disability manifested by dizziness and episodes of passing out was caused by the service-connected diabetes mellitus or service-connected gastrointestinal disability? Please explain the basis for the opinion. c) Is it as likely as not (i.e., to a probability of 50 percent or greater) that the Veteran's disability manifested by dizziness and episodes of passing out was aggravated (i.e., permanently worsened beyond the normal progression) by the service-connected diabetes mellitus or service-connected gastrointestinal disability? Please explain the basis for the opinion. If the examiner opines that the Veteran's disability was aggravated (permanently worsened in severity beyond the normal progression) by service-connected disability, the examiner should attempt to identify the baseline level of severity of the disability manifested by dizziness and passing out before the onset of aggravation. The term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation or aggravation as to find against causation or aggravation. If the opinions and/or supporting rationale cannot be provided without invoking processes relating to guesses or judgment based upon mere conjecture, the examiner should clearly so specify in the report, and explain why this is so. 2. Obtain a supplemental medical opinion, preferably from the same examiner who conducted the January 2013 VA examination, if available, addressing the etiology of the Veteran's current erectile dysfunction. If another medical examination is necessary in order to provide the requested medical opinion, please so schedule. The relevant documents from the record should be provided to the VA examiner for review. The examiner should confirm review of the record in the examination report. Based on review of the appropriate records, the examiner should offer opinions on the following questions: a) Is it as likely as not (i.e., to a probability of 50 percent or greater) that the Veteran's erectile dysfunction was caused by service-connected diabetes mellitus? Please explain the basis for the opinion. b) Is it as likely as not (i.e., to a probability of 50 percent or greater) that the Veteran's erectile dysfunction was aggravated (i.e., permanently worsened beyond the normal progression) by service-connected diabetes mellitus? Please explain the basis for the opinion, to include discussion of medical literature showing that diabetes mellitus is a risk factor for ED. If the examiner opines that the Veteran's erectile dysfunction was aggravated (permanently worsened in severity beyond the normal progression) by his diabetes mellitus, the examiner should attempt to identify the baseline level of severity of the erectile dysfunction before the onset of aggravation. The term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation or aggravation as to find against causation or aggravation. If the opinions and/or supporting rationale cannot be provided without invoking processes relating to guesses or judgment based upon mere conjecture, the examiner should clearly so specify in the report, and explain why this is so. 3. Arrange for a VA general medical examination for pension purposes to determine the extent and severity of all of the non-service connected disabilities present, and whether those disabilities are permanent in nature. The relevant documents from the record should be provided to the VA examiner and should be reviewed by the VA examiner in connection with the examination. The examiner should confirm review of the record in the examination report. An interview of the Veteran regarding the relevant medical and work history, a physical examination, and all tests and studies required to respond to the following questions should be performed. The examiner should also identify the level of functional impairment associated with all such disabilities shown, and indicate whether they are permanent in nature, and if so, constitute sufficient impairment of mind or body to render it impossible for the average person to follow a substantially gainful occupation, and/or render the Veteran incapable of substantially gainful employment. The examiner should set forth all examination findings, along with the complete rationale for the conclusions reached. 4. When the development above has been completed, the remanded issues should be readjudicated. If any benefit sought is not granted, the Veteran should be furnished a Supplemental Statement of the Case and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of the claim. See 38 C.F.R. § 3.655 (2012). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ C. FERGUSON Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs