Citation Nr: 1328464 Decision Date: 09/06/13 Archive Date: 09/16/13 DOCKET NO. 09-42 219A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a right eye disability. 2. Entitlement to service connection for a left eye disability. 3. Entitlement to service connection for a neurological disability, right upper extremity. 4. Entitlement to service connection for a neurological disability, left upper extremity. 5. Entitlement to service connection for a neurological disability, right lower extremity. 6. Entitlement to service connection for a neurological disability, left lower extremity. 7. Entitlement to service connection for a prostate disability. 8. Entitlement to service connection for a psychiatric disorder, other than posttraumatic stress disorder (PTSD). 9. Entitlement to an initial disability evaluation in excess of 70 percent for PTSD. 10. Entitlement to an initial disability evaluation in excess of 60 percent for coronary artery disease with myocardial infarction. 11. Entitlement to an initial disability evaluation in excess of 10 percent for diabetes mellitus with associated nephropathy, hypertension and erectile dysfunction. 12. Entitlement to an initial disability evaluation in excess of 10 percent for residuals of a cerebrovascular accident. 13. Entitlement to a total disability rating based on individual unemployability (TDIU). 14. Entitlement to an effective date earlier than March 8, 2007, for the award of service connection for diabetes mellitus. 15. Entitlement to an effective date earlier than March 8, 2007, for the award of service connection for PTSD. 16. Entitlement to an effective date earlier than March 8, 2007, for the award of service connection for coronary artery disease with myocardial infarction. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD S. Coyle, Counsel INTRODUCTION The Veteran served on active duty from April 1967 to April 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal of September 2008, January 2009, and March 2009 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The issues with respect to service connection for vision loss and a psychiatric disorder other than PTSD, and increased ratings for diabetes mellitus and coronary artery disease, have been recharacterized to comport with the evidence of record. The September 2008 rating decision denied entitlement to service connection for polyps. The Veteran initiated a timely appeal by filing a notice of disagreement to that decision later that month. A statement of the case (SOC) was issued in April 2011; however, the Veteran did not perfect a timely appeal of the issue, and the decision is now final. In January 2012, the Veteran communicated a desire to reopen the claim of entitlement to service connection for polyps. The matter is referred to the agency of original jurisdiction for disposition. The increased rating claims, the claim for a TDIU, and all service connection claims except the issue of service connection for a right eye disability are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. A December 2004 rating decision denied entitlement to service connection for PTSD and coronary artery disease. Although notified of the determination and of his appellate rights in January 2005, the Veteran did not initiate an appeal within one year of being notified. 2. No further claim for service connection for PTSD or coronary artery disease was received until March 8, 2007. 3. A June 2005 rating decision severed service connection for diabetes mellitus. Although notified of the determination and of his appellate rights in September 2005, the Veteran did not initiate an appeal within one year of being notified. 4. No further claim for service connection for diabetes mellitus was received until March 8, 2007. 5. The Veteran has a right eye disability that is as likely as not caused by the service-connected cerebrovascular accident. CONCLUSIONS OF LAW 1. The criteria for assignment of an effective date earlier than March 8, 2007, for the grant of service connection for PTSD are not met. 38 U.S.C.A. §§ 5107, 5110 (West 2002); 38 C.F.R. § 3.400 (2013). 2. The criteria for assignment of an effective date earlier than March 8, 2007, for the grant of service connection for coronary artery disease are not met. 38 U.S.C.A. §§ 5107, 5110 (West 2002); 38 C.F.R. § 3.400 (2013). 3. The criteria for assignment of an effective date earlier than March 8, 2007, for the grant of service connection for diabetes mellitus are not met. 38 U.S.C.A. §§ 5107, 5110 (West 2002); 38 C.F.R. § 3.400 (2013). 4. The criteria for service connection for a right eye disability are met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist Upon receipt of a complete or substantially complete application, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. Regarding the claim for service connection for a right eye disability, the Board is granting in full the benefit sought on appeal. Accordingly, any error committed with respect to either the duty to notify or the duty to assist was harmless and will not be further discussed. The remaining appeals arise from the Veteran's disagreement with the effective dates assigned following grants of service connection for PTSD, coronary artery disease, and diabetes mellitus. Once an initial claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial and will not be discussed. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Veteran's medical treatment records have been obtained; he did not identify any outstanding records pertinent to the appeal. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. There is no indication that he receives disability benefits from the Social Security Administration. No VA examinations have been conducted in connection with the claims for an earlier effective date, but none is required because medical examinations would in no way assist the Veteran in establishing his claims. There is no indication in the record that any additional evidence, relevant to the issues decided, is available and not part of the claim file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). Service Connection Law and Regulations Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury or disease diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (1995). Secondary service connection will be granted when a disability is proximately due to or the result of a service connected disease or injury. 38 C.F.R. § 3.310. Secondary service connection may be established for a disorder which is aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Facts VA clinical notes reflect that the Veteran experienced a cerebrovascular accident in May 2007. Service connection for stroke residuals has been established. A May 24, 2007 note describes a "right hemanioptic visual field cut" along with other residuals of the stroke. During a September 2008 VA eye consult, the Veteran reported that his right eye visual field defect began after his May 2007 stroke. The optometrist stated, however, that the Veteran has "severe restriction OD [right eye]" which was "not consistent with" stroke. The Veteran underwent a VA eye examination in October 2008. The right eye visual field defect was "not consistent with diabetes diagnosis and [stroke]"; however, it was noted that the Veteran was scheduled for an upcoming MRI "for further investigation of visual field deficit." A December 2008 MRI of the Veteran's brain "showed no acute changes or masses to explain the [visual field defect.]" As a result, the Veteran's VA optometrist determined that the right eye visual field defect was "most likely associated to remote stroke." The Veteran received another VA eye consult in August 2011. The Veteran reported loss of visual field immediately following his May 2007 stroke. The examiner characterized his right eye visual field defect as resulting in "legal blindness." An MRI showed atrophy of the optic nerve, leading to a diagnosis of "[central retinal artery occlusion] with residual cilio-retinal artery to fovea." Analysis The September 2008 consult included a finding that the Veteran's visual field defect was not consistent with diabetes or stroke; it noted that the Veteran was scheduled for an MRI to further investigate the cause of his visual field defect. The December 2008 MRI showed no evidence of any other brain changes that could explain the Veteran's visual field defect, leading the Veteran's VA optometrist to reverse his September 2008 opinion and find that his visual field defect was "most likely associated to remote stroke." This finding is supported by other medical evidence of record and consistent with the Veteran's report of visual field defect immediately following a stroke in May 2007. The October 2008 VA examiner did not provide an addendum evaluating the MRI findings and updating his opinion. Because the examination is not reasonably based on all of the evidence of record, it is of no probative value. An August 2011 eye consult described the Veteran's reports of an onset of right visual field loss immediately following his stroke in May 2007. An MRI showed atrophy of the optic nerve, consistent with a "central-retinal artery occlusion." The examiner did not indicate that a central-retinal artery occlusion is a new and separate condition from the service- connected cerebrovascular accident. The Veteran reported a right eye visual field defect immediately after the May 2007 stroke, and has continued to report the symptoms since that time. The Veteran is competent to report such symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). No evidence diminishes the credibility of his assertions. Affording the Veteran the benefit-of-the-doubt, it is at least as likely as not that he has a right eye disorder that was incurred as a result of his service-connected stroke. Service connection for a right eye disorder is warranted. See 38 U.S.C.A §5107 (West 2002). Earlier Effective Dates Law and Regulations The provisions of the law governing effective date of awards of benefits are clear. The effective date of an award is generally the date of receipt of a claim (or informal claim where appropriate), or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400. More specifically, the effective date of an award of disability compensation for direct service connection is the day following separation from active service or the date entitlement arose, if the claim was received within one year after separation from service; otherwise, it is the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2)(i). If a veteran files an application for service connection with VA and the claim is disallowed, he has the right to appeal that disallowance to the Board. See 38 U.S.C.A. §§ 7104, 7105. If he does not initiate an appeal within one year, or if he initiates a timely appeal and the appeal is denied, the disallowance becomes final. See 38 C.F.R. §§ 20.302, 20.1100, 20.1103. With exceptions not here applicable, any award based on a subsequently filed application for benefits can be made effective no earlier than the date of the new application. See 38 C.F.R. § 3.400(q), (r). Generally, a specific claim in the form prescribed by the Secretary must be filed in order for benefits to be paid to any individual under the laws administered by VA. See 38 C.F.R. § 3.151(a). However, any communication or action, indicating intent to apply for one or more benefits under the laws administered by VA, from a claimant, his or her duly authorized representative, a Member of Congress, or some person acting as next friend of a claimant who is not sui juris may be considered an informal claim. Such informal claim must identify the benefit sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within 1 year from the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155. VA must look to all communications from a claimant that may be interpreted as applications or claims - formal and informal - for benefits and is required to identify and act on informal claims for benefits. Servello v. Derwinski, 3 Vet. App. 196, 198 (1992). If VA fails to forward an application form to the claimant after receipt of an informal claim, then the date of the informal claim must be accepted as the date of claim for purposes of determining an effective date. Servello, 3 Vet. App. at 200. Facts Service connection for diabetes mellitus was initially granted by a May 2004 rating decision, on the basis that the Veteran had a diagnosis of diabetes mellitus and proof of exposure to herbicides during his Vietnam service. Service connection for PTSD and coronary artery disease was denied by a December 2004 rating decision, because the Veteran's PTSD stressors could not be verified, and because coronary artery disease was not shown during service and there was no nexus to service or to a service-connected disability. The Veteran was notified of this decision and did not appeal. The December 2004 decision also proposed to sever service connection for diabetes mellitus, as a result of a VA examination showing no evidence of diabetes. The Veteran disagreed with that proposal in January 2005. In June 2005, service connection for diabetes mellitus was severed. The Veteran was notified of this decision and did not appeal. In March 2007, the Veteran filed claims for service connection for PTSD, coronary artery disease, and diabetes mellitus. During the development of the claim for service connection for PTSD, the Veteran's military stressors were corroborated by the Joint Services Records Research Center. Service connection for PTSD was awarded in a September 2008 rating decision, and an effective date of March 8, 2007 was assigned. In a January 2009 rating decision, service connection for diabetes mellitus was re-established, and an effective date of May 30, 2007, was assigned. A subsequent December 2011 rating decision awarded an effective date of March 8, 2007. The decision noted a confirmed diagnosis of diabetes mellitus, and noted that the findings of impaired glucose tolerance prior to the effective date of service connection were not indicative of diabetes. The January 2009 rating decision also awarded service connection for coronary artery disease, as secondary to the service-connected diabetes mellitus, effective March 8, 2007, the effective date of service connection for diabetes. Analysis The RO denied the Veteran's claims for service connection for PTSD and coronary artery disease in December 2004, and severed service connection for diabetes mellitus in June 2005. Although notified of the determinations and of his appellate rights, the Veteran did not initiate appeals of these decisions. As a result, they became final. Review of the file does not reveal, nor does the Veteran allege, any subsequent claim for service connection, formal or informal, filed before March 8, 2007. Accordingly, the effective date of the subsequent awards of service connection for PTSD, diabetes mellitus and coronary artery disease can be no earlier than March 8, 2007. Special Considerations The Veteran asserts that retroactive effective dates are permissible under the facts of this case. Indeed, retroactive effective dates are allowed, to a certain extent, in cases where an award or increase of compensation is granted pursuant to a liberalizing law. 38 U.S.C.A. § 5110(g) ; 38 C.F.R. § 3.114(a). Under these provisions, the claimant must have met all eligibility criteria for the liberalized benefit on the effective date of the liberalizing law or VA issue, and have been continuously eligible from that date to the date of claim or administrative determination of entitlement. These provisions apply to original and reopened claims, as well as claims for increase. Id.; see also McCay v. Brown, 9 Vet. App. 183, 188 (1996), aff'd, 106 F.3d 1577, 1581 (Fed. Cir. 1997). In such cases, the effective date of the award or increase shall be fixed in accordance with the facts found, but shall not be earlier than the effective date of the liberalizing law or VA issue. 38 C.F.R. § 3.114(a). For claims received more than one year after the effective date of the liberalizing law or VA issue, benefits may be authorized for a period of one year prior to the date of receipt of the request for review. Id. VA has also promulgated special rules for the effective dates for the grant of presumptive service connection based on exposure to herbicides pursuant to orders of a United States District Court in the class action of Nehmer v. United States Department of Veterans Affairs. See 38 C.F.R. § 3.816; see also Nehmer v. United States Veterans Administration, 712 F. Supp. 1404 (N.D. Cal. 1989) (Nehmer I); Nehmer v. United States Veterans Administration, 32 F. Supp. 2d. 1175 (N.D. Cal. 1999) (Nehmer II); Nehmer v. Veterans Administration of the Government of the United States, 284 F.3d 1158 (9th Cir. 2002) (Nehmer III). A Nehmer class member is defined as a Vietnam veteran who has a covered herbicide disease, such as coronary artery disease or diabetes. Certain effective dates apply if a Nehmer class member was denied compensation for a covered herbicide disease between September 25, 1985, and May 3, 1989; or if there was a claim for benefits pending before VA between May 3, 1989, and the effective date of the applicable liberalizing law. See 38 C.F.R. § 3.816(c)(1)- (3). The liberalizing law that added diabetes as a disease presumptively due to herbicide exposure during service in Vietnam became effective on May 8, 2001. Although service connection for diabetes mellitus as a result of herbicide exposure was granted after the liberalizing law, the Veteran was not continuously eligible for service connection for diabetes mellitus from May 8, 2001, until the award of service connection. In fact, service connection for diabetes was severed in June 2005. While a subsequent VA examination did diagnose diabetes mellitus, the examiner also found that the findings of impaired glucose tolerance prior to that date did not constitute a diagnosis of diabetes. Since the Veteran was not continuously eligible for service connection for diabetes mellitus from May 8, 2001, entitlement to an effective date earlier than March 8, 2007, is not available as a result of a liberalizing law. 38 U.S.C.A. § 5110(g) ; 38 C.F.R. § 3.114(a). The Veteran was not denied compensation for diabetes between September 25, 1985 and May 3, 1989, or between May 3, 1989 and the effective date of the liberalizing law on May 8, 2001. Thus, the special rules afforded to Nehmer class claimants are also not applicable. The claim for an earlier effective date for coronary artery disease was granted prior to the liberalizing law establishing coronary artery disease as a disease presumptively due to herbicide exposure, which became effective on August 31, 2010. Thus, entitlement to an effective date earlier than March 8, 2007 for coronary artery disease is not available as a result of a liberalizing law. 38 U.S.C.A. § 5110(g) ; 38 C.F.R. § 3.114(a). The Veteran was denied compensation for coronary artery disease in December 2004, which is between May 3, 1989, and the effective date of the liberalizing law on August 31, 2010. However, service connection for coronary artery disease was not granted pursuant to that liberalizing law. Rather, it was awarded in January 2009, as secondary to diabetes mellitus. Thus, the special rules afforded to Nehmer class claimants are not applicable. With respect to the claim for an earlier effective date for PTSD, the claim was granted prior to the liberalizing law requiring only that a Veteran show fear of hostile military or terrorist activity to satisfy the in-service incurrence element of a claim for service connection for PTSD. 75 Fed. Reg. 39852 (July 13, 2010). Thus, entitlement to an effective date earlier than March 8, 2007 for PTSD is not available as a result of the liberalizing law. 38 U.S.C.A. § 5110(g) ; 38 C.F.R. § 3.114(a). The preponderance of the evidence is against the claims for earlier effective dates; there is no doubt to be resolved; and effective dates earlier than March 8, 2007, for the award of service connection for PTSD, diabetes mellitus, and coronary artery disease is not warranted. ORDER Entitlement to service connection for a right eye disability, as secondary to a service-connected disability, is granted. Entitlement to an effective date earlier than March 8, 2007, for the award of service connection for diabetes mellitus is denied. Entitlement to an effective date earlier than March 8, 2007, for the award of service connection for PTSD is denied. Entitlement to an effective date earlier than March 8, 2007, for the award of service connection for coronary artery disease with myocardial infarction is denied. REMAND A January 2009 rating decision granted entitlement to service connection for coronary artery disease. In March 2009, the Veteran filed a notice of disagreement (NOD) with respect to the assigned rating. No statement of the case (SOC) has been issued. When an NOD has been filed with regard to an issue, and a SOC has not been issued, the appropriate Board action is to remand the issue to the agency of original jurisdiction for issuance of a SOC. Manlincon v. West, 12 Vet. App. 238 (1999). Over four years have elapsed since the Veteran was last afforded a VA examination for his PTSD and diabetes mellitus. In a June 2013 statement, the Veteran's representative asserted that the symptomatology associated with these disabilities has worsened since then. When a veteran claims that his condition is worse than when originally rated, and the available evidence is too old for an adequate evaluation of the veteran's current condition, VA's duty to assist includes providing a new examination. See Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993). The Veteran must be afforded VA examinations for the purpose of ascertaining the current severity of his service-connected PTSD and diabetes mellitus. The PTSD examiner must also determine whether the Veteran has any psychiatric disorder other than PTSD, and, if so, state the medical probabilities that it was incurred as a result of his service or a service-connected disability. The Veteran was afforded a VA examination of his stroke residuals in February 2012. Although some residuals were identified, the examination report does not identify the affected nerves or adequately describe the level of impairment; thus, the examination report is inadequate for rating purposes. The examination report also did not determine whether the Veteran has any neurological abnormalities in his right upper and lower extremities. The Veteran must be afforded an additional VA examination for the purpose of ascertaining the nature and severity of any service-connected stroke residuals. The Veteran asserts that his prostate disease was caused by the service-connected diabetes mellitus or exposure to herbicides in service. An examination of the Veteran's prostate must be scheduled and an etiology opinion obtained. The TDIU question is inextricably intertwined with the increased rating claims and identification of any additional service connected conditions or manifestations. TDIU is dependent upon consideration of the impact of all service connected conditions on the ability to obtain or retain substantially gainful employment. Harris v. Derwinski, 1 Vet. App. 180 (1991). Thus, this claim must be held in abeyance pending resolution of the increased rating claims and service-connection claims. Accordingly, the case is REMANDED for the following action: 1. Obtain all VA records since November 2011. 2. Request that the Veteran identify all non-VA treatment providers who have treated him for his claimed disabilities. After obtaining his written authorization, obtain a complete copy of the Veteran's records from the identified treatment providers. 3. Schedule the Veteran for a VA examination to determine the current level of severity of the Veteran's PTSD. The examiner must thoroughly review the Veteran's claim file, to include a copy of this remand. The examination must include a detailed account of all manifestations of PTSD found to be present. The examiner must describe how the symptoms of the service- connected PTSD affect the Veteran's social and industrial capacity. All necessary special studies or tests including psychological testing are to be accomplished. The examiner is to assign a numerical code under the Global Assessment of Functioning Scale (GAF). The examiner must also provide an opinion as to whether it is at least as likely as not that the Veteran has any other psychiatric disorders that are at least as likely as not related to his active military service, or, alternatively, caused or aggravated by a service- connected disability. All opinions must be set forth in detail and explained in the context of the record. The term "aggravation" means a permanent increase in the claimed disability; that is, an irreversible worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 4. Schedule the Veteran for a VA neurological examination. The examiner must describe the nature and severity of all residuals of the Veteran's cerebrovascular accident, including left- sided hemiparesis and a swallowing disorder. For all identified neurological residuals, the examiner must state the particular peripheral nerves affected. The level of nerve impairment for each such nerve must be equated with "mild," "moderate," "moderately severe," or "severe" disability. If there is complete paralysis of the nerve, the examiner must so state. The examiner must also determine the nature and severity of any other stroke residuals identified on examination, so that each of these abnormalities may be definitively evaluated for rating purposes. In addition to an opinion regarding the severity of the Veteran's stroke residuals, the examiner must provide an opinion as to whether it is at least as likely as not that the Veteran has any neurological abnormalities in his right upper and lower extremities that are at least as likely as not related to his active military service, or, alternatively, caused or aggravated by a service-connected disability. All opinions must be set forth in detail and explained in the context of the record. The term "aggravation" means a permanent increase in the claimed disability; that is, an irreversible worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 5. Schedule the Veteran for a VA examination to assess the current severity of his service-connected diabetes mellitus. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner must thoroughly review the Veteran's claim file, to include a copy of this remand. The examiner is to identify all complications of the Veteran's service- connected diabetes mellitus, and indicate the severity of each complication. The examiner is to state whether or not the Veteran's type II diabetes mellitus requires regulation of activities (i.e., avoidance of strenuous occupational and recreational activities) and/or insulin. The examiner must also state the frequency of visits to diabetic care providers, as well as the frequency of episodes of ketoacidosis and hypoglycemia resulting in hospitalization, if any. 6. Schedule the Veteran for a VA genitourinary examination by an appropriate medical professional. The entire claim file (i.e., the paper claim file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be reviewed by the examiner. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claim file so they can be available to the examiner for review. The examiner is to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any prostate disease is related to service, including as a result of exposure to herbicides, or aggravated by the service-connected diabetes mellitus. The term "aggravation" means a permanent increase in the claimed disability; that is, an irreversible worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 7. Develop and adjudicate the increased rating claims and claims for service connection. 8. Following a decision on the increased rating claims and claims for service connection, schedule the Veteran for a VA examination in connection with his claim for a TDIU. The claims folder must be reviewed in conjunction with the examination. The examiner is to determine the extent to which all of the Veteran's service- connected disabilities, taken as a whole, (currently PTSD at 70%; coronary artery disease at 60%; diabetes mellitus and stroke residuals, each at 10%; and diabetic nephropathy, noncompensable) affect his ability to obtain or retain substantially gainful employment, without regard to his age or nonservice connected disabilities. If any increased rating claims or claims for service connection are granted, these disorders must be considered in determining their effect on his employability. Thus, the examiner must be advised of all service-connected disabilities prior to rendering his/her opinion on the issue of employability. A complete rationale for all opinions expressed must be provided. 9. Issue a SOC for the issue of entitlement to an increased initial rating for coronary artery disease, so that the Veteran may have the opportunity to complete an appeal on this issue (if he so desires) by filing a timely substantive appeal. This issue should only be returned to the Board if a timely substantive appeal is filed. 10. Then, readjudicate the appeal. If any of the benefits sought remain denied, issue a supplemental statement of the case and return the case to the Board. The appellant has the right to submit additional evidence and argument on the matters 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 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). ______________________________________________ RONALD W. SCHOLZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs