Citation Nr: 1327925 Decision Date: 08/30/13 Archive Date: 09/05/13 DOCKET NO. 08-16 852 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, the Republic of the Philippines THE ISSUES 1. Entitlement to service connection for hypertension, including as due to exposure to herbicides. 2. Entitlement to service connection for cataracts of the right eye, including as due to exposure to herbicides. 3. Entitlement to service connection for residuals of post-surgical right eye pseudophakia, including as due to exposure to herbicides. 4. Entitlement to service connection for peripheral neuropathy, including as due to exposure to herbicides. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD R. Casadei, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active duty service from July 1954 to January 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Manila, the Republic of the Philippines, which, in pertinent part, denied the claims on appeal. The Veteran presented testimony at a Board personal hearing before the undersigned Veterans' Law Judge in July 2009 in Manila, Republic of the Philippines. A transcript of this hearing has been associated with the Veteran's claims folder. The issues on appeal were previously remanded by the Board in November 2009 for further evidentiary development to obtain VA examinations for the disabilities. This was accomplished and, in a June 2013 rating decision, the RO granted service connection for cataract and residuals of post-surgical pseudophakia with cystoids macular edema of the left eye. The remaining claims were readjudicated in a June 2013 supplemental statement of the case. For the reasons discussed in detail below, the Board concludes that the November 2009 Board remand directives have been substantially complied with in regard to the claims for service connection for hypertension, right eye cataract, and residuals of post-surgical right eye pseudophakia, including as due to exposure to herbicides, and it may proceed with a decision at this time. See 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 (Fed. Cir. 2002). The issue of service connection for peripheral neuropathy, including as due to exposure to herbicides, is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran was exposed to herbicides while serving in the Republic of Vietnam. 2. The Veteran has currently diagnosed hypertension. 3. Service treatment records reveal a one-time blood pressure reading of 136/90 during service. 4. Symptoms relating to hypertension were not chronic in service and have not been continuous since service separation. 5. Hypertension did not manifest in service or within one year of service separation. 6. The Veteran's currently diagnosed hypertension is not etiologically related to service. 7. The Veteran does not have currently diagnosed disability of right eye cataract or any residuals from post-surgical right eye pseudophakia. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension, including as due to exposure to herbicides, have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). 2. The criteria for service connection for cataracts of the right eye, including as due to exposure to herbicides, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). 3. The criteria for service connection for residuals of post-surgical right eye pseudophakia, including as due to exposure to herbicides, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes 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). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. The Board finds that the VCAA notice requirements have been satisfied by an April 2007 letter. In this letter, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate a claim for service connection as well as what information and evidence must be submitted by the Veteran and what evidence VA would obtain. The VCAA 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) 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. The United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection was awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, the April 2007 letter included the type of evidence necessary to establish a disability rating and effective date. Regarding the duty to assist, VA must make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the service connection claims currently on appeal, the evidence of record includes service treatment records, service personnel records, private treatment records, the Veteran's statements, and VA examination reports obtained pursuant to the November 2009 Board remand directives. The May 2011 VA hypertension examination and June 2012 VA eye examination reports included a review the Veteran's claims file and medical history, recorded pertinent examination findings, and provided conclusions and opinions with supporting rationale. The VA examination reports are probative with regard to those service connection claims on appeal. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). As the Board will discuss in more detail in the remand section below, a supplemental VA medical opinion is warranted in order to assist in determining the etiology of the Veteran's peripheral neuropathy disability. For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. Service Connection Laws 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, 1131; 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). The Board finds that hypertension is a "chronic disease" listed under 38 C.F.R. § 3.309(a) (2012); therefore, the Board will apply 38 C.F.R. § 3.303(b) to the hypertension disability issue. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). On the other hand, right eye cataracts and pseudophakia are not chronic diseases under 38 C.F.R. § 3.309(a) and those claims will be adjudicated using the general principles of service connection. Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946 develops certain chronic diseases, such hypertension, to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Generally, 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). In the case of a veteran who engaged in combat with the enemy in a period of war, lay evidence of in-service incurrence or aggravation of a disease or injury shall be accepted if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the lack of official record of such incurrence or aggravation. See 38 U.S.C.A. § 1154(b); Libertine v. Brown, 9 Vet. App. 521, 524 (1996); Collette v. Brown, 82 F.3d 389, 392-94 (Fed. Cir. 1996). The standard used to determine whether a veteran engaged in combat with the enemy is reasonable doubt, which is to be resolved in a veteran's favor. See VAOPGCPREC 12-99. The provisions of 38 U.S.C.A. § 1154(b), however, can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to a current disorder. See Libertine, 9 Vet. App. at 522-23. The provisions of 38 U.S.C.A. § 1154(b) do not establish service connection for a combat veteran; it aids a veteran by relaxing the adjudicative evidentiary requirements for determining what happened in service. Clyburn v. West, 12 Vet. App. 296, 303 (1999). 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. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. " Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii). The following diseases are deemed associated with herbicide exposure, under VA law: AL amyloidosis, Chloracne or other acneform disease consistent with chloracne, Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes), Hodgkin's disease, Ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), Multiple myeloma, Non-Hodgkin's lymphoma, Parkinson's disease, Acute and subacute peripheral neuropathy, Porphyria cutanea tarda, Prostate cancer, Respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and Soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). In Combee v. Brown, the United States Court of Appeals for the Federal Circuit held that when a veteran is found not to be entitled to a regulatory presumption of service connection for a given disability the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed.Cir.1994), reversing in part Combee v. Principi, 4 Vet. App. 78 (1993). As such, the Board must not only determine whether the Veteran has a disability which is recognized by VA as being etiologically related to prior exposure to herbicide agents that were used in Vietnam, but must also determine whether his current disability is the result of active service under 38 U.S.C.A. § 1110 and 38 C.F.R. § 3.303(d). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 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. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert, 1 Vet. App. at 57. 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"). 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 the 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, including by a veteran. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner's 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). Service Connection for Hypertension The Veteran contends that currently diagnosed hypertension is related to his in-service exposure to herbicides (Agent Orange) while serving in the Republic of Vietnam. At the outset, although the Board finds that the Veteran served in Vietnam during the Vietnam Era, and is presumed to have been exposed to herbicide agents during service, hypertension is not among the diseases listed under 38 C.F.R. § 3.309(e), for which presumptive service connection based on herbicide exposure is available; therefore, there is no basis for a presumptive grant of service connection for hypertension. 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. In this regard, the Board finds that the Veteran has currently diagnosed hypertension. See February 2007 St. Michael Medical Center treatment record and May 2011 VA examination report. Further, the Board finds that, although service treatment records reflect a one-time blood pressure reading of 136/90, symptoms relating to hypertension were not chronic in service. The Board notes that under 38 C.F.R. § 4.104, Diagnostic Code 7101, hypertension is defined as a systolic blood pressure of 160 mm Hg, a diastolic blood pressure of 90, or a combination of both. Service treatment records reflect that blood pressure readings from 1954 to 1974 were all normal except for one isolated reading of 136/90 in January 1968. No medical intervention was indicated in the medical examination form at that time. Further, the last documented blood pressure reading in the service separation examination in January 1974 was 122/74, that is, within normal limits. See 38 C.F.R. § 4.104, Diagnostic Code 7101. Further, in a January 1974 report of medical history, the Veteran denied having high or low blood pressure. Had the Veteran experienced chronic elevated blood pressure readings during service, the Veteran would have had symptoms or would have been diagnosed or treated for such during service. For these reasons, the Board finds that the Veteran's hypertension symptoms were not chronic in service; therefore, presumptive service connection under 38 C.F.R. § 3.303(b) for "chronic" symptoms in service is not warranted. The Board also finds that the weight of the probative evidence demonstrates that hypertension did not manifest to a compensable degree within one year of service separation. The weight of the evidence demonstrates no symptoms relating to hypertension during the one year period after service, and no diagnosis or findings of hypertension during the one year post-service presumptive period. See 38 C.F.R. §§ 3.307, 3.309. As will be discussed in detail below, the evidence shows the first assessment of hypertension, based on the Veteran's own reported history, began in the 1990s, approximately two decades after service separation. The first objective medical evidence of record establishing a diagnosis of hypertension was in 2004, approximately 30 years after service separation. See February 2007 St. Michael Medical Center treatment record. For these reasons, the Board finds that hypertension did not manifest to a compensable degree within one year of service separation; therefore, the presumptive provisions for hypertension are not applicable in this case. 38 C.F.R. §§ 3.307, 3.309. The Board next finds that the weight of the evidence demonstrates that symptoms associated with hypertension have not been continuous since service separation. Upon review of the evidence of record, the Board finds that the objective medical evidence does not demonstrate any diagnosis or treatment relating to hypertension until 2004, approximately 30 years after service separation. In his April 2007 claim for VA compensation, the Veteran reported that his hypertension began in service in 1973 and has continued since that time; however, upon review of the record, the Board finds that the Veteran's statements are not credible regarding continuous symptoms of hypertension since service separation. For example, during the May 2011 VA examination report the Veteran reported that his hypertension had its onset in the 1990s; however, in a February 2007 treatment note from the St. Michaels Medical Center reveals a notation from the doctor stating that the Veteran had hypertension for three years (i.e., 2004). Further, at no time since service separation has the Veteran reported in-service onset or continuous symptoms of hypertension since service separation to medical professional. The Board finds that the absence of any history of in-service onset or post-service continuous symptoms to be highly probative as these statements were made for treatment purposes prior to his filing of a compensation claim. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994). The Board further finds the lack of complaints, diagnosis, and treatment from medical professionals for 30 years to be another factor weighing against the Veteran's claim. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). The Board finds the February 2007 private treatment records and the history given by the Veteran at that time for treatment purposes to weigh against a continuing symptomatology after service separation and also as to the Veteran's credibility. Accordingly, the Board finds that the Veteran's hypertension symptoms have not been continuous since service separation. For these reasons, the Board finds that presumptive service connection under 38 C.F.R. § 3.303(b) for continuous post-service symptoms is not warranted. The Board further finds that the weight of the competent and probative evidence demonstrates that the currently diagnosed hypertension is not related to or caused by service, to include herbicide exposure. Although private treatment records discuss continued treatment for hypertension, these records do not provide an opinion as to whether hypertension is related to service, to include in-service herbicide exposure. The Veteran was afforded a VA examination in May 2011 to assist in determining whether the Veteran's hypertension was related to service, to include herbicide exposure in service. The May 2011 VA examiner noted that the claims file was reviewed, to include the in-serve treatment records from 1954 to 1974. The May 2011 VA examiner also interviewed the Veteran, reported the relevant medical history, conducted a physical examination (including blood pressure readings), and diagnosed the Veteran with hypertension. Then, the May 2011 VA examiner opined that it was less likely than not that the Veteran's hypertension was causally related to service. Based on the available information, the May 2011 VA examiner reasoned that the serial blood pressure readings from 1954 to 1974 were all normal except for one isolated reading of 136/90 in January 1968. The VA examiner noted that the in-service medical report did not indicate that any medical intervention was conducted at the time. Further, the Veteran's last documented blood pressure reading in January 1974 was 122/74. Based on the Veteran's reports, the VA examiner noted that treatment was started well after service separation in the 1990s. The May 2011 VA examiner further opined that hypertension was not caused by herbicide exposure. The Board has also considered the Veteran's statements, to include the July 2009 hearing testimony, asserting a nexus between his currently-diagnosed hypertension and service. While the Veteran is competent to report symptoms as they come to him through his senses, hypertension, which requires blood pressure readings to diagnose and has symptoms similar to other diagnoses, which would require the ability to differentiate the symptoms from all other diagnoses, is not the type of disorder that a lay person can provide competent evidence on questions of etiology. See Layno, 6 Vet. App. at 465 (competent lay evidence is evidence not requiring that the proponent have specialized education, training, or experience, but is provided by a person who has knowledge of facts or circumstances and conveys matter that can be observed and described by a lay person); see also Rucker at 74 (stating that a lay person is not competent to diagnose or make a competent nexus opinion about a disorder as complex as cancer). Here, the Board finds that the Veteran does not have the education, training, or experience to provide a competent opinion as to the etiology of hypertension, especially in the context of absence of symptoms or treatment for decades after service. Instead, the Board finds the May 2011 VA medical opinion to be the most competent and probative evidence of record. Based on the evidence of record, both lay and medical, the Board finds that the weight of the competent and probative evidence is against a finding of relationship between the Veteran's currently diagnosed hypertension and service, to include in-service exposure to herbicides. For these reasons, the Board finds that a preponderance of the evidence is against the claim for service connection for hypertension, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Service Connection for Right Eye Cataracts and Residuals of Pseudophakia The Veteran filed his claim for service connection for cataracts of the right and left eye in April 2007. In a June 2013 rating decision, the RO granted service connection for left eye cataract, residuals of post-surgical pseudophakia with cystoids macular edema. Accordingly, the Board will consider only the Veteran's right eye disabilities. The evidence reflects that in September 2004, three year prior to his claim for VA compensation, the Veteran underwent cataract surgery on both eyes resulting in intraocular lens implants (pseudophakia). According to a June 2010 VA examination report, the Veteran recovered well from cataract surgery on the right eye, but did not recover well on the left eye and had to undergo a second surgery in October 2004 for a vitrectomy for retained cortical fragment in the left eye. Upon review of the evidence of record, the Board finds that the Veteran does not have a current disability of right eye cataract or residuals from post-surgical pseudophakia in the right eye. "Cataract" is defined, in pertinent part, as "a partial or complete opacity on or in the lens of the eye." See Dorland's Illustrated Medical Dictionary 303 (32nd ed. 2012). As the Veteran's right eye natural lens was removed and replaced with a intraocular lens implant (pseudophakia) in 2004, the Veteran has not had a right eye cataract during the claim period (i.e., 2007 to the present) or even immediately prior to the claim period. See June 2010 VA examination report (noting that right eye lens had been removed). There are no other diagnoses relating to the Veteran's right eye, to include residuals from pseudophakia in the right eye. Accordingly, in the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). For these reasons, the Board finds that service connection for right eye cataracts and residuals of post-surgical right eye pseudophakia, to include as due to herbicide exposure, is not warranted. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim must be denied. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for hypertension, including as due to exposure to herbicides, is denied. Service connection for cataracts of the right eye, including as due to exposure to herbicides, is denied. Service connection for residuals of post-surgical right eye pseudophakia, including as due to exposure to herbicides, is denied. REMAND In regard to the issue of service connection for peripheral neuropathy, to include as due to herbicide exposure, the Board finds that a remand is warranted in order to obtain a supplemental VA medical opinion. The Veteran contends that service connection for peripheral neuropathy is warranted on the basis that his current peripheral neuropathy of the upper and lower extremities is the result of exposure to herbicides in service. See Veteran's claim for VA compensation dated April 2007 and the June 2007, June 2010, and March 2011 VA examination reports. Further, in a July 2009 statement, the Veteran stated that his right arm numbness may be due to a mass in his right elbow found and removed during service. See in-service treatment record dated December 1960. The Veteran was first diagnosed with peripheral neuropathy of the upper and lower extremities in February 2007, over 30 years after service separation. There are two VA medical opinions of record which discuss the likely etiology of the peripheral neuropathy. The first, dated June 2010, diagnosed idiopathic peripheral neuropathy. The June 2010 VA examiner opined that, based on the Veteran's statements that he experienced tingling and pain in his upper and lower extremities in 1975, one year after service separation, the peripheral neuropathy was as least as likely as not caused by or a result of in-service exposure to Agent Orange. The second VA medical opinion, dated March 2011, noted that the record was devoid of any treatment records used to justify the statement that the peripheral neuropathy had its onset in 1975. The March 2011 VA examiner further noted that an opinion as to the etiology of the peripheral neuropathy could not be rendered without resorting to mere speculation. There are several deficiencies with the VA medical opinions of record regarding the Veteran's peripheral neuropathy. First, neither of the VA examiners addressed the Veteran's theory that his currently diagnosed peripheral neuropathy may be related to his in-service right elbow mass, which was surgically removed in service. See in-service treatment record dated December 1960. Further, the June 2010 opinion was unaccompanied by any rationale. Despite the positive nexus opinion, the June 2010 VA examiner did not address how the Veteran's peripheral neuropathy was related to in-service herbicide exposure despite evidence demonstrating that the Veteran does not have acute or subacute peripheral neuropathy as defined by regulation. See Note 2 under 38 C.F.R. § 3.309(e) ("the term acute and subacute peripheral neuropathy means transient peripheral neuropathy that appears within weeks or months of exposure to an herbicide agent and resolves within two years of the date of onset"). Moreover, although the March 2011 VA examiner provided two supporting medical articles that peripheral neuropathy was a known disorder related to herbicide exposure, the cited medical article from M. Dobbs is not available to the Board for review and the VA examiner did not provide a summary or description of its findings. The March 2011 VA examiner also did not provide any explanation as to why an opinion was not possible or feasible, such as there were multiple possible etiologies with none more prevalent than another, the limits of medical knowledge had been exhausted in this subject matter area, or the examiner needed the benefit of additional evidence, information or other procurable data. For these reasons, the Board is requesting another VA medical opinion to assist in determining whether currently diagnosed peripheral neuropathy is related to service, to include exposure to herbicides or an in-service elbow disorder. Accordingly, the issue of service connection for peripheral neuropathy, including as due to exposure to herbicides is REMANDED for the following action: 1. The RO/AMC should request a new VA medical opinion to assist in determining the etiology of the Veteran's peripheral neuropathy disability. The relevant documents in the claims folder should be made available to the examiner for review. The examiner should review the relevant evidence, to include the Veteran's lay statements. All tests and studies deemed necessary should be accomplished and clinical findings should be reported in detail. The VA examiner should render opinions as to the following: (a) Does the Veteran have currently diagnosed acute or subacute peripheral neuropathy? (Note: the term acute and subacute peripheral neuropathy means transient peripheral neuropathy that appears within weeks or months of exposure to an herbicide agent and resolves within two years of the date of onset). (b) If the Veteran does not have acute or subacute peripheral neuropathy, is it at least as likely as not that currently diagnosed peripheral neuropathy is related to the right elbow condition diagnosed in service? (See December 1960 service treatment record). (c) Is it at least as likely as not that the currently diagnosed peripheral neuropathy disability is related to the Veteran's exposure to herbicides (Agent Orange) in service? The VA examiner is asked to discuss the findings in the June 2010 and March 2011 VA examination reports, to include the medical literature referenced by the March 2011 examiner. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The VA examiner should provide a rationale for his or her opinion with references to the evidence of record and should provide a discussion of the facts and medical principles involved. Referenced medical literature should be available for review to the Board or otherwise properly summarized by the examiner. 2. When the development requested has been completed, the RO/AMC should readjudicate the appeal in light of any additional evidence added to the claims file. If the benefit sought is not granted, the Veteran should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs