Citation Nr: 1328517 Decision Date: 09/06/13 Archive Date: 09/16/13 DOCKET NO. 94-18 894 ) 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 an eye disorder, other than conjunctivitis with loss of vision, to include as secondary to service-connected pulmonary tuberculosis. 2. Entitlement to service connection for bilateral hearing loss disability. 3. Entitlement to service connection for tinnitus. 4. Entitlement to service connection for irritable bowel syndrome, to include as a medically unexplained chronic multisymptom illness. 5. Entitlement to service connection for ischemic heart disease and hypertensive cardiovascular disease with angina, to include as secondary to service-connected mitral valve prolapse. 6. Entitlement to service connection for diabetes mellitus, to include as secondary to ischemic heart disease and hypertensive cardiovascular disease with angina. 7. Entitlement to service connection for Bell's palsy with facial numbness. 8. Entitlement to service connection for dengue hemorrhagic fever. 9. Entitlement to service connection for erectile dysfunction to include as secondary to service-connected prostatis. 10. Entitlement to service connection for posttraumatic stress disorder (PTSD). 11. Entitlement to an increased rating for mitral valve prolapse, currently rated as 10 percent disabling. 12. Entitlement to an increased rating for keratosis pilaris/folliculitis, currently rated as 30 percent disabling. 13. Entitlement to an increased rating for tinea pedis, currently rated as 10 percent disabling. 14. Entitlement to a compensable rating for chondromalacia of the knees. 15. Entitlement to a compensable rating for hemorrhoids prior to January 15, 2012. 16. Entitlement to a rating in excess of 20 percent for hemorrhoids since January 15, 2012. 17. Entitlement to a compensable rating for lipomas of the abdomen, chest, and back, status post excision. 18. Entitlement to a total disability rating by reason of individual unemployability (TDIU). REPRESENTATION Appellant represented by: Daniel G. Krasnegor, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Smith, Counsel INTRODUCTION The Veteran had active service from August 1961 to September 1991. These matters initially came before the Board of Veterans' Appeals (Board) on appeal from multiple RO rating decisions. The Veteran provided testimony at a personal hearing held at the San Diego, RO before a Hearing Officer in January 1994. A transcript of the hearing has been associated with the record. In March 2003, the Board denied entitlement to an initial evaluation in excess of 10 percent for conjunctivitis. In January 2004 the parties, appellant and appellee, moved the United States Court of Appeals for Veterans Claims (Court) to vacate and remand the Board's March 2003 decision. In January 2004 the Court entered an Order vacating the March 27, 2003 decision and remanding it to the Board for further action consistent with its Order. In September 2004, the Board remanded the claim to the RO for additional development to include a VA examination of the Veteran. The Board again denied this claim in an August 2006 decision. This appeal involves numerous issues arising from different rating decisions of the RO as far back as 1991. After multiple Board remands, the Board denied 26 claims in an August 2008 decision. In a February 2010 Memorandum Decision, the Court vacated the Board's decision on each claim and remanded them to the Board. In March 2011, the Board remanded the matter for development in accordance with the directives of the Court's February 2010 Memorandum Decision. The Board notes that the issues captioned above differ from those before the Board in March 2011. Given the complexity of this matter, the Board finds it would be helpful to explain these differences. Subsequent to the March 2011 remand, a number of claims were granted by the RO in an April 2012 rating decision. As such, the claims are no longer in appellate status and will not be addressed below. See generally Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997); Barrera v. Gober, 122 F.3d 1030 (Fed. Cir. 1997). Taking the issues in chronological order from the title page of the Board's March 2011 decision, these claims include: issues #1 (service connection for a low back disability), #2 (service connection for a sprained left ankle), # 6 ( service connection for a chronic lung disorder manifested by positive protein derivative (PPD) or tine test), # 8 (service connection for prostatitis), # 9 (service connection for rheumatoid arthritis), # 10 (service connection for osteoarthritis, degenerative and post- traumatic), # 11 (service connection for bronchopneumonia), # 12 (service connection for peptic ulcer disease), # 15 (service connection for acute pyelonephritis), and # 16 (service connection for a liver condition). The issues captioned above also differ slightly from those listed on the most recent supplemental statement of the case (SSOC) of April 2012, and from those most recently enumerated by the Veteran's attorney in a June 2013 brief. The issue involving an increased rating for hemorrhoids is not listed on the April 2012 SSOC. In an April 2012 rating decision, in an April 2012 rating decision, the evaluation assigned to the Veteran's hemorrhoids was increased to 20 percent, effective January 15, 2012. As this rating is less than the maximum benefit available for the period of time prior to January 15, 2012, the issue remains on appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993). The claim has been recharacterized as shown on the title page, to depict the staged rating assigned. The SSOC also does not include a claim for entitlement to service connection for IBS. In the Board's March 2011 remand, a claim for entitlement to service connection for a gastrointestinal disorder manifested by indigestion or gastritis (Issue # 7) was included in the appeal. In the RO's April 2012 rating decision, service connection was granted for "peptic ulcer disease and gastritis." While this would appear to be a grant of the benefit sought, the Veteran's attorney has continued to present argument for entitlement to service connection for a gastrointestinal disorder, specifically, IBS. See June 2013 Brief. As such, the claim remains in appellate status. Finally, the SSOC does not contain the claim for a TDIU. The Veteran's attorney has requested a TDIU due to the service-connected disabilities for which higher ratings are sought. Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court of Appeals for Veterans Claims (Court) held that a claim for TDIU, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. As such, the Board has characterized the appeal as encompassing a claim for a TDIU. Additionally, in the Veteran's attorney's June 2013 brief, the attorney did not address the claim for hemorrhoids as an issue on appeal. For the reasons described above however, and as the claim was not withdrawn, it remains in appellate status. The attorney combined the increased rating claims for keratosis and tinea pedis into one issue (#12 on Brief), which accounts for a difference in the total number of claims enumerated as being on appeal. The Veteran's attorney also presented argument on the following claim not depicted on the title page above, or in the April 2012 SSOC: entitlement to promulgation of the April 2012 rating decision (#1 on Brief).. Promulgation of the April 2012 rating decision will be accomplished by the RO and is not part of the present appeal. Finally, theories of entitlement based on secondary service connection and presumptive service connection available to Persian Gulf Veterans have been included in the characterizations above, to more accurately reflect the Veteran's actual arguments and assertions. See June 2013 Brief. The Board notes that although additional medical evidence was submitted after the last supplemental statement of the case, in June 2013, the Veteran's representative waived the right to have this evidence reviewed in the first instance by the RO. The Board has considered documentation included in the Virtual VA system in reaching the determinations below. No new records pertinent to this appeal were found therein. In an April 2012 VA examination report, the examiner found the Veteran suffers from an additional skin condition that is likely related to his service-connected keratosis. This issue has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The claims for service connection for an eye disorder, bilateral hearing loss disability, tinnitus, irritable bowel syndrome, ischemic heart disease and hypertensive cardiovascular disease with angina, diabetes mellitus, Bell's palsy, erectile dysfunction, and PTSD, as well as the rating claims on appeal (Issues # 11-16), are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office. FINDING OF FACT Dengue hemorrhagic fever was not manifest during service and is not attributable to service. CONCLUSION OF LAW Dengue hemorrhagic fever was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & 2012); 38 C.F.R. §§3.102, 3.159, 3.303 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Notice and Assistance Under applicable law, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Board finds that the content requirements of a duty to assist notice have been fully satisfied. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Letters from the RO dated in June 2001, January 2003, September 2006, and March 2007 provided the Veteran with an explanation of the type of evidence necessary to substantiate his claim as well as an explanation of what evidence was to be provided by him and what evidence the VA would attempt to obtain on his behalf. The 2006 and 2007 letters additionally provided him with information concerning the evaluation and effective date that could be assigned should service connection be granted, pursuant to Dingess v. Nicholson, 19 Vet. App. 473 (2006). VA has no outstanding duty to inform the Veteran that any additional information or evidence is needed. VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Here, the Board finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issue has been obtained. The Veteran's service treatment records and post service treatment records have been obtained. He has been afforded a VA medical opinion for the claim decided herein. The Veteran was also afforded an opportunity to present testimony at a hearing before the RO. For all of these reasons, the Board does not have notice of any additional relevant evidence which is available but has not been obtained. The Board is further satisfied that the RO has substantially complied with its March 2011 remand directives as they pertain to the claim decided herein. Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board engagement letter requesting a medical opinion is required). As directed by the Board, the AOJ secured a VA medical opinion for the claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). In this vein, the Board observes that while a VA medical opinion was secured, the Veteran was not afforded an actual VA examination in connection with the claim. As explained further below however, the Board, finds that no such actual examination is required for this claim. Indeed, the Veteran's attorney has not requested that an actual examination be conducted for this claim. See June 2013 Brief. For the foregoing reasons, the Board concludes that all reasonable efforts were made by the VA to obtain evidence necessary to substantiate the Veteran's claim. Therefore, no further assistance to the Veteran with the development of evidence is required. Law & Regulations Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be warranted 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). In relevant part, 38 U.S.C.A. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a disorder when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted.") The record shows that for four days in June 1996, the Veteran was hospitalized for fever, epistaxis, and blackish stools. He was diagnosed with dengue hemorrhagic fever. He does not contend that this disability is secondary to any other disability, so analysis in this regard is unnecessary. Also, while the Veteran in this case qualifies as a Persian Gulf Veteran, he has a known diagnosis and dengue hemorrhagic fever is not otherwise a qualifying chronic disability. See 38 C.F.R. § 3.317. Additionally, while the Veteran served during the Vietnam Era, there is no evidence to support, and the Veteran does not contend, that he served in the Republic of Vietnam or was exposed to herbicides. As such, consideration of service connection on the basis of Persian Gulf service or on the basis of herbicide exposure is not warranted. Thus, the question is whether his current disability is related to active service or events therein. See 38 C.F.R. § 3.303. As for the in-service incurrence of the condition, initially, the Board notes that the Veteran does not claim that his dengue hemorrhagic fever is due to combat. Therefore, the combat provisions of 38 U.S.C.A. § 1154 (West 2002) are not applicable. The Veteran's service treatment records are devoid of any documentation of dengue hemorrhagic fever. His statements have not been specific as to how the condition arose in service. In April 2012, a VA medical opinion for this claim was obtained. The examiner reviewed the Veteran's claims files. He found that it was less likely than not that the Veteran's dengue hemorrhagic fever was incurred in or caused by service. He found, No report of dengue [sic] hemorrhagic fever was noted in service, this is a self limiting condition and is caused by a mosquito bite; recovery occurs within a week after the finding of low platelet or bleeding and leaves no residuals. The diagnosis of hemorrhagic fever with blackish stools on January [sic] 24, 1996, was beyond one year from discharge and the absence of a similar condition during service makes it less likely as not related to any incident in service. The only possible medical opinion to the contrary is a January 2009 statement from a private physician who stated that all of the Veteran's illnesses, impairments, and disabilities are related to service. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). The Board finds here that the opinion of the April 2012 VA examiner outweighs that of the private physician. The private physician's statement is general and does not actually mention dengue hemorrhagic fever. There is no rationale for the opinion. There is no indication that the private physician reviewed the Veteran's claims file or that he had an accurate history. The Board does not discount the opinion solely on this basis, but finds this fact significant because it does not appear the Veteran's service treatment records were reviewed. It is thus unclear how the physician determined that the Veteran's dengue hemorrhagic fever was related to service. Again, his conclusion in this regard was unsupported by any rationale. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.") By contrast, the April 2012 opinion is adequate for the purposes of adjudication. A rationale for the conclusion reached was provided. The applicable and appropriate history was noted, and there is no showing that the report provided a substantially different picture of the Veteran's disability than the other evidence in the claims file. The medical examiner's findings were factually accurate and fully articulated, and valid medical analyses were applied. See Nieves-Rodriguez, 22 Vet. App. at 304. The only other evidence of record supporting the Veteran's claim are his lay assertions, which are competent. See Jandreau, 492 F.3d at 1376-77. The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. Buchanan v. Nicolson, 451 F.3d 1331 (Fed. Cir. 2006). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, 6 Vet. App. at 465 (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). To the extent the Veteran attempts to establish a lay nexus, we find such assertion to be not credible. The Veteran's lay assertions are in conflict with the overall findings of the evidence of record and the more probative evidence regarding etiology tends to weigh against such a finding. Thus, the Board finds that the lay opinion is less informed, less probative and less credible than the reasoned medical opinion. The Board finds the opinion of the April 2012 VA examiner to be more probative. The VA examiner is a medical professional who has reviewed the claims file and considered the reported history. The examiner used his expertise in reviewing the facts of this case, and determined that the current dengue hemorrhagic fever was unrelated to service. It is clear that the examiner fully understood the basis for the Veteran's claim yet still determined, after reviewing the facts of the case, that the dengue hemorhhagic fever was related to causes other than disease or injury incurred during the Veteran's period of service. The Veteran has not suggested that the April 2012 report was prepared in an insufficient manner. The Board acknowledges that while a medical opinion has been obtained, an actual examination of the Veteran has not been conducted. In this regard, the Board finds the April 2012 medical opinion fully sufficient for purposes of adjudication, as described above, and that all information necessary to decide the claim has been obtained. The intent of the Board's March 2011 remand in this regard has been satisfied. Indeed, the Veteran's attorney has not requested that an actual examination be conducted for this claim. See June 2013 Brief. Finally, the United States Court of Appeals for the Federal Circuit recently clarified that the continuity of symptomatology language in § 3.303(b) "restricts itself to chronic diseases" found in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As dengue hemorrhagic fever is not a chronic disease under § 3.309(a), §3.303(b) is not applicable. The Veteran and his family members are competent to report that he has had symptoms of dengue hemorrhagic fever since service. See, 38 C.F.R. § 3.303(a). However, those opinions and statements pale in significance to the medical evidence that clearly establishes that there was no such pathology during service, that there was a remote onset, and that the current disease is unrelated to service. Here, the medical evidence is far more persuasive and credible than the lay assertions. The Board has considered the articles submitted by the Veteran in the course of the appeal. This evidence, however, does not address the facts that are specific to this Veteran's case. As such, the Board finds that the information reflected in the submitted articles is not probative of the medical questions at issue in this appeal. The Board also recognizes that the Veteran has submitted copies of past Board decisions. To the extent the Veteran cites to the Board's disposition of other cases as precedential in establishing his claim, the Board notes that prior Board decisions are not precedential. See 38 C.F.R. § 20.1303 (2012). Rather, the Board must weigh the facts of each case and apply the governing laws and regulations without regard to dispositions in other appellants' cases based on separate and unique facts. In short, there is competent evidence that the Veteran had dengue hemorrhagic fever in the course of the appeal; however, the more probative and credible evidence establishes that there is no relationship to service. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for dengue hemorrhagic fever is denied. REMAND In August 2008, the Board denied the claims on appeal due to the Veteran's failure to attend scheduled VA examinations, pursuant to the provisions of 38 C.F.R. § 3.655. Under 38 C.F.R. 3.655(a), "when entitlement or continued entitlement to a benefit cannot be established or confirmed without a current VA examination or reexamination and a claimant, without good cause, fails to report for such examination, or reexamination, action shall be taken in accordance with paragraph (b) or (c) of this section as appropriate. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant, death of an immediate family member, etc." 38 C.F.R. §3.655(b) provides, "when a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. When the examination was scheduled in conjunction with any other original claim, a reopened claim for a benefit which was previously disallowed, or a claim for increase, the claim shall be denied." In an April 2007 letter, prior to the examinations, the Veteran's representative submitted a letter indicating that the Veteran could not attend the scheduled examinations because of severe illness. In the February 2010 Memorandum Decision, the parties found that the Board failed to adequately explain why the Veteran's illness did not constitute "good cause" for his absence at VA examinations. For this reason, the Board's October August 2008 decision on 23 of 26 claims was set aside. As for 2 of the remaining claims, entitlement to service connection for PTSD and hearing loss disability, the Court found the Board had provided an inadequate statement of reasons and bases for its determination to not award service connection. As for the final remaining claim, entitlement to service connection for tinnitus, the Court found the Board erred in determining that VA fulfilled its duty to assist in developing the claim. In March 2011, the Board ordered the RO to schedule VA examinations for the 23 claims. A VA audiological examination was separately ordered for the Veteran's claims for hearing loss disability and tinnitus. As for the PTSD claim, development was ordered to determine whether the Veteran engaged in combat. The Veteran did not appear for the examinations scheduled. Instead, the RO obtained medical opinions, without an examination of the Veteran, for a number claims on appeal. Unfortunately, as described below, as pertinent to the claims for increased ratings for mitral valve prolapse, keratosis, tinea pedis, chondromalacia of the knees, and lipomas, the medial opinions obtained do not contain information in conformity with the rating schedule so as to allow application of the appropriate diagnostic codes in rating each disability. Similarly, as described below, further medical information is needed to fairly adjudicate the service connection claims remaining on appeal. In the June 2013 Brief, the Veteran's attorney argues that his inability to travel should be treated in the same was as an incarcerated Veteran, as he too is confined. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (holding those who adjudicate claims of incarcerated Veterans [are] to be certain that they tailor their assistance to the peculiar circumstances of confinement.) The attorney further asserts that unlike an incarcerated Veteran who has been confined for his own wrongdoing, the Veteran here is confined to his home due to infirmity, much of it related to illnesses that have been attributed to his 30 years of service. Private medical records confirm the allegations that the Veteran is confined to his home, as they generally depict a dire situation. The Veteran's attorney asserts the Veteran is able and willing to participate in a VA examination to the extent possible, so long as he is not required to travel to an examination site. On review of the Memorandum Decision and the arguments presented, the Board finds that one, final attempt should be made to schedule the Veteran for VA examinations in connection with his claims. The Veteran's inability to attend VA examinations was a fact in evidence before the Court, yet the Court still ordered VA to examine him, or to attempt to explain why his illness was not good cause for a failure to attend. As such, the Board in 2011 remanded the claims for VA examinations. While it is not within the province of the Board to control the policies pertaining to administering VA examinations, given the Court's concerns, and the Veteran's attorney's arguments, the Board finds that one final attempt should be made to assess the current severity of his service-connected disabilities, and to obtain needed opinions on the service connection claims. Taking the increased rating claims first, as for mitral valve prolapse, ratings are assigned pursuant to 38 C.F.R. 4.100, Diagnostic Code 7000, based on MET levels, combined with particular symptomatology. The April 2012 VA medical opinion does not contain the necessary information. Recognizing this, and accounting for private medical records submitted, in the April 2012 SSOC the RO advised the Veteran that a separate development letter would be sent to him, requesting specific information from his private physicians so as to enable the disability to be evaluated. As described in the June 2013 Brief by the Veteran's attorney, this letter was never sent. Moreover, reconciliation is needed of the symptoms attributable to mitral valve prolapse versus his ischemic heart disease and hypertensive cardiovascular disease. Both keratosis and tinea pedis are rated pursuant to 38 C.F.R. 4.100, Diagnostic Code 7806, based on the percentage of total body or exposed areas affected, combined with particular treatment requirements and other symptomatology. The April 2012 VA medical opinion does not contain this information. Further, an examination is needed to reconcile the symptoms associated with the Veteran's service-connected keratosis and tinea pedis, with the symptoms of non-service connected skin problems. For example, the April 2012 VA examiner found that the Veteran also suffers from a separate skin condition, manifested by infected lesions, a watery skin appearance, and pus cells, which have proliferated all over the anatomical body. The Veteran's chondromalacia of the knees has been rated pursuant to 38 C.F.R. 4.71a, Diagnostic Code 5257, based on recurrent subluxation and instability. The Board notes that in April 2012, the Veteran was separately service-connected for arthritis of the knees, and did not appeal this decision. The April 2012 VA medical opinion contains no findings regarding instability or subluxation. The Veteran's lipomas have been rated pursuant to 38 C.F.R. 4.71a, Diagnostic Code 7819. This diagnostic code rates based on either limitation of function, or scar symptomatology. The April 2012 medical opinion does not contain applicable findings. The remaining increased claim to be discussed is the claim for hemorrhoids. While the April 2012 VA medical opinion may be sufficient for rating this claim, and current findings are not necessary as the Veteran is receipt of the maximum benefit allowable under the applicable diagnostic code, due process requires a remand of this claim. As noted, a staged rating was assigned to the Veteran's disability by way of an April 2012 rating decision. However, the benefit sought was not granted in full, as a 2012 effective date was assigned for the increase, and this stems from a 1992 claim. Despite this, the RO failed to issue an SSOC. This does not comply with the Board's March 2011 remand directives. Turing to the service connection claims, as for an eye disorder, the April 2012 VA examiner opined that the Veteran's eye disorders were not related to any incident of active service. However, the evidence involving secondary service connection should be reconciled. For example, in October 2004, a private physician attributed a number of eye problems, including optic neurophathy, hypertensive retinopathy, diabetic retinopathy, astigmatism, and microaneurism to various disorders, including hypertension, diabetes, and PTSD. In the June 2013 Brief, the Veteran's attorney asserted that the Veteran has toxic optic neuropathy secondary to his service-connected pulmonary tuberculosis. As the April 2012 VA examiner did not offer an opinion on secondary service connection, this information should be sought. Additionally, as the record indicates the Veteran has been diagnosed with multiple eye disorders other than conjunctivitis; an opinion for each should be sought. As for bilateral hearing loss disability and tinnitus, the April 2012 VA examiner stated he could not render an opinion on the claims without resort to mere speculation as the Veteran needed to be examined or undergo a legitimate hearing evaluation before a conclusion could be reached. The Board notes that a March 1984 record shows a scarred tympanic membrane. The Veteran complained of hearing loss in service in May 1991, and tinnitus in August 1991. Prior VA examiners, including examiners in July 1998 and November 2000, have failed to render an opinion concerning the etiology of these disorders. In January 2011, a private physician offered an opinion on the Veteran's hearing loss, attributing it to infections in service from water getting in the ears, but it is unclear whether this provider actually examined the Veteran's hearing or reviewed the claims file in rendering this opinion. A direct service connection opinion, based on an examination of the Veteran, should be sought. As for IBS, the Veteran's attorney seeks presumptive service connection for this disorder due to the Veteran's status as a Persian Gulf Veteran. In this case, the Veteran is service-connected for peptic ulcer disease and gastritis. A medical opinion is needed to confirm a diagnosis of IBS, and to distinguish his symptoms of IBS from his peptic ulcer disease and gastritis. As for ischemic heart disease and hypertensive cardiovascular disease with angina, the Veteran's attorney seeks an additional medical opinion in order to flesh out the issue of aggravation/causation of this disability by the Veteran's service-connected mitral valve prolapse. Further, the Board finds that current testing as determined by the examiner, to possibly include an echocardiogram, may be helpful in this regard. As the Veteran seeks service connection for diabetes mellitus on a secondary basis to this disability, the claims should be decided together. As for Bell's Palsy, a May 1997 private medical report documents this condition. The March 2012 VA examiner opined that the disorder was less likely as not incurred in or caused by service. As rationale, the examiner relied on an absence of any documentation of Bell's Palsy in the claims file, a finding that is factually inaccurate given the May 1997 medical record. Additionally, a January 2012 private medical record attributes the Bell's Palsy to the Veteran's mitral valve prolapse. The April 2012 examiner prepared two reports pertinent to the Veteran's heart disabilities, and identified numerous related disorders, but did not include Bell's Palsy among them. Opinions on direct and secondary service connection should be sought. As for erectile dysfunction, the evidence involving secondary service connection should be reconciled. For example, in December 1999 the Veteran's private physician appears to relate the disorder to his gastrointestinal problems. On VA examination in November 2000, the examiner opined that his erectile dysfunction was "probably" due to diabetes. The March 2012 VA examiner determined that because the November 2000 examiner found the condition was probably related to diabetes, it was less likely as not related to service. As for PTSD, pursuant to the Board's March 2011 remand directives, in the April 2012 supplemental statement of the case (SSOC), the RO conceded the Veteran's combat status. Specifically, based on history of the U.S.S. Ranger (CVA-61, later CV-61), from the Naval Historical Center, from late 1990 to April 1991 the ship was in the Persian Gulf to participate in brief, but very intense "Desert Storm" fighting. The Veteran was aboard the ship at this time. A Performance Evaluation Report for the period of June 29, 1990 to April 30, 1991 showed his participation in the combat environment of Operation Desert Storm. The Veteran provided full service to Ranger's crew 24 hours per day to match continuous combat operations. A diagnosis of PTSD by the Veteran's private physician has been documented numerous times throughout the appeal, and the private physician has indicated the condition is related to Gulf Service. However, reports contain no reference to the DSM-IV in rendering the diagnosis, in accordance with VA regulation, namely, 38 C.F.R. § 4.125(a). Additionally, this physician also diagnosed the Veteran with a variety of other psychiatric disorders, including psychosis, manic depressive disorder, and a condition manifested by a nervous breakdown with insomnia. See, e.g., January 2012 private medical report. An opinion should be sought as to each disorder. Further, in adjudicating this claim, the RO should consider the revised 38 C.F.R. § 3.304(f)(3). The provisions of 38 C.F.R. § 3.317 should also be considered in adjudicating the claim. With regard to the claim for TDIU, the Board finds that any decision with respect to the claims remanded herein may affect the Veteran's claim for a TDIU. Therefore, the claims are inextricably intertwined. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). As the claims should be considered together, it follows that any Board action on the TDIU claim, at this juncture, would be premature. Hence, a remand of this matter is warranted. Finally, the United States Court of Appeals for Veterans Claims (Court) has held that the failure by the BVA to enforce compliance with the requirements of 38 U.S.C.A. § 5103(a) for the VA to inform a claimant of the information or evidence necessary to substantiate a claim, as well as to inform a claimant of which evidence the VA would seek to provide and which evidence the claimant is to provide, is remandable error. In this case, it does not appear that the Veteran has been notified of what evidence is necessary to substantiate a claim for service connection on a secondary basis. The Court has indicated that such specific notice is required to comply with the law. Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Therefore, upon remand, the Veteran should be provided proper notice. Accordingly, the case is REMANDED for the following action: 1. Send the Veteran VCAA notice under 38 U.S.C.A. §5103(a) and 38 C.F.R. § 3.159(b) for the claims on appeal. The notice should include an explanation as to what information or evidence is needed to substantiate a secondary service connection claim. 2. Afford the Veteran a VA examinations to address the current severity of his mitral valve prolapse, keratosis, tinea pedis, chondromalacia of the knees, and lipomas. The examiner is to be provided access to the claims folder, a copy of this remand, and Virtual VA. In accordance with the latest worksheets for rating each particular disorder, the examiner is to provide a detailed review of the Veteran's pertinent medical history, current complaints, and the nature and extent of the Veteran's disability. A complete rationale for any opinions expressed must be provided. 3. The Veteran should be afforded VA examinations to address the nature and likely etiology of his eye disorder (other than conjunctivitis with loss of vision), bilateral hearing loss disability, tinnitus, Bell's palsy, and erectile dysfunction. The examiner is to be provided access to the claims folder and Virtual VA as needed. Any and all indicated studies deemed necessary by the examiner should be accomplished. For each disorder, the examiner is requested to review all pertinent records associated with the claims file and offer comments and an opinion addressing whether it is at least as likely as not (50 percent probability or greater) that the disorder is due to an injury or other event or incident of his period of active service. For each disorder, the examiner should additionally offer comments and an opinion addressing whether it is at least as likely as not that the disorder was caused or aggravated (permanently made worse) by a service-connected disability. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. The Veteran should be afforded a VA examination by a cardiologist to address the nature and likely etiology of his ischemic heart disease and hypertensive cardiovascular disease with angina. The examiner is to be provided access to the claims folder and Virtual VA as needed. Any and all indicated studies deemed necessary by the examiner should be accomplished. The examiner is requested to review all pertinent records associated with the claims file and offer comments and an opinion addressing whether it is at least as likely as not (50 percent probability or greater) that the ischemic heart disease and hypertensive cardiovascular disease with angina is due to an injury or other event or incident of his period of active service. The examiner should additionally offer comments and an opinion addressing whether it is at least as likely as not that the ischemic heart disease and hypertensive cardiovascular disease with angina was caused or aggravated (permanently made worse) by a service- connected disability, to include mitral valve prolapse. In so doing, the examiner should address the findings of the April 2012 VA examiners. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. The Veteran should be afforded a VA examination by an endocrinologist to address the nature and likely etiology of his diabetes mellitus. The examiner is to be provided access to the claims folder and Virtual VA as needed. Any and all indicated studies deemed necessary by the examiner should be accomplished. The examiner is requested to review all pertinent records associated with the claims file and offer comments and an opinion addressing whether it is at least as likely as not (50 percent probability or greater) that the diabetes mellitus is due to an injury or other event or incident of his period of active service. The examiner should additionally offer comments and an opinion addressing whether it is at least as likely as not that the diabetes mellitus was caused or aggravated (permanently made worse) by a service-connected disability, to include mitral valve prolapse. In so doing, the examiner should address the findings of the March 2012 and April 2012 VA examiners. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 6. Schedule the Veteran for a Persian Gulf War protocol examination to determine whether his current psychiatric problems or irritable bowel syndrome may be a manifestation of a larger undiagnosed illness. The claims file, including a complete copy of this remand, must be made available to the physician(s) designated to examine the Veteran for his pertinent medical and other history. The report of the examination(s) should include discussion of his documented medical history and assertions. All appropriate tests and studies and/or consultation(s) should be accomplished (with all findings made available to the examiner(s) prior to the completion of his or her report), and all clinical findings should be reported in detail. The examiner should conduct a comprehensive medical evaluation and provide details about the onset, frequency, duration, and severity of the Veteran's symptoms. a. the examiner should specifically state whether the Veteran's psychiatric problems and irritable bowel syndrome are attributable to known clinical diagnoses, or are part of a larger undiagnosed illness. If there are known clinical diagnoses that can be medically explained, the examiner should expressly indicate these underlying diagnoses. In such a case, the VA examiner should further opine, following a review of the claims folder, on the etiology of the Veteran's each disorder by addressing the following question: is it at least as likely as not (i.e., probability of 50 percent) that the disorder was incurred in service? b. If, on the other hand, the Veteran suffers from signs or symptoms that are determined not to be associated with a known clinical diagnosis, the examiner must note that fact. 7. Schedule the Veteran for VA examination by a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted. On examination, the examiner should report all psychiatric disabilities found to be present. After examining the Veteran and reviewing the claims file, the examiner should respond to the following: Does the appellant have PTSD? If he has PTSD, are the symptoms related to his conceded combat duty in the Persian Gulf War, or his fear of in-service hostile military or terrorist activity? In the alternative, the examiner is asked to express an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that any other current psychiatric disorder(s) was/were manifested during or otherwise related to service? If so, clearly identify such current psychiatric disorder(s). The examiner should provide an adequate rationale for all opinions expressed and conclusions reached. 8. The Veteran should be notified that it is his responsibility to report for the examinations and to cooperate in the development of the claims. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). 9. In scheduling and conducting these examinations, it is requested that in- home VA examinations be considered, due to the Veteran's physical inability to travel to an examination site. If in-home examinations are not possible, that fact and the reasons for it must be noted in the file. In such a case, for the service connection claims, the RO should request a VA medical opinion without examination responsive to the questions posed hereinabove. For the increased rating claims, the RO should request from his private physicians who are familiar with the current severity of his conditions, for any specific medical information necessary for to adjudicate each claim under the rating schedule. All correspondence should be associated with the claims file. 10. After the completion of any action deemed appropriate in addition to that requested above, the appellant's claims should be readjudicated. All applicable laws and regulations should be considered. If any benefit sought remains denied, the appellant should be provided a supplemental statement of the case and given the opportunity to respond. The appellant 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). 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). _________________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs