Citation Nr: 1329054 Decision Date: 09/11/13 Archive Date: 09/17/13 DOCKET NO. 10-36 437 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to a rating in excess of 10 percent for right knee strain with degenerative joint disease. 2. Whether new and material evidence has been submitted to reopen a previously denied claim of entitlement to service connection for mucoepidermoid carcinoma. 3. Whether new and material evidence has been submitted to reopen a previously denied claim of entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for mucoepidermoid carcinoma. 5. Entitlement to service connection for bilateral hearing loss. 6. Entitlement to service connection for tinnitus. 7. Entitlement to service connection for hypertension. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Andrew Mack, Counsel INTRODUCTION The Veteran served on active duty from August 1965 to April 1972. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. In August 2011, the Veteran testified during a Board videoconference hearing before the undersigned Acting Veterans Law Judge (AVLJ). A transcript of that hearing is included in the claims file. At the time of the hearing, the Veteran submitted additional evidence along with a waiver of initial RO review of such evidence, and it will therefore be considered by the Board. See 38 C.F.R. § 20.1304(c). Also, additional VA medical records, including treatment records and an examination dated in May 2013, have been associated with the claims file but have not been reviewed by the RO. However, such records do not relate to or have a bearing on the issues decided herein, and therefore the Board need not refer the records for initial RO consideration prior to deciding these matters on the merits. Id. During his August 2011 Board hearing, the Veteran stated that he had symptoms of diabetes and was "kind of borderline on that too." However, the Veteran did not assert that he actually has diabetes, and has not filed a claim for service connection for diabetes or indicated an intent to file any such claim. Thus, if the Veteran wishes to file a claim for service connection for diabetes, he should do so with the RO as appropriate. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. The issues of a rating in excess of 10 percent for right knee strain with degenerative joint disease and service connection for mucoepidermoid carcinoma 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. The claims for service connection for mucoepidermoid carcinoma and for bilateral hearing loss were previously denied by the RO in decisions in March 2005 and April 2006, respectively; the Veteran did not appeal either decision, and no new evidence pertinent to either claim was received by VA within one year from the date that the RO mailed notice of either determination to the Veteran. 2. The additional evidence received since the final rating decisions in March 2005 and April 2006 has not been previously considered by the RO and it relates to unestablished facts necessary to substantiate each claim. 3. The Veteran is shown to have served in the Republic of Vietnam during the Vietnam era. 4. The Veteran was exposed to loud noise (acoustic trauma) while in service. 5. The Veteran did not experience chronic symptoms of bilateral hearing loss or tinnitus during service. 6. The Veteran did not experience continuous symptoms of bilateral hearing loss in the years after service. 7. The Veteran did not experience recurrent symptoms of tinnitus in the years after service. 8. A bilateral hearing loss was not manifested to a degree of ten percent within one year of service separation. 9. Bilateral hearing loss and tinnitus first manifested many years after service separation and are not related to service. 10. The Veteran did not experience chronic symptoms of hypertension during service. 11. The Veteran did not experience continuous symptoms of hypertension in the years after service. 12. Hypertension was not manifested to a degree of ten percent within one year of service separation. 13. The Veteran's hypertension first manifested many years after service separation and is not related active service including in-service exposure to herbicides including Agent Orange. CONCLUSIONS OF LAW 1. The April 2006 rating decision denying service connection for carcinoma of the jaw became final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.104, 3.156(b) (2012). 2. The April 2006 rating decision denying service connection for bilateral hearing loss became final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.104, 3.156(b) (2012). 3. The additional evidence received since the April 2006 rating decision is new and material, and the claim for service connection for mucoepidermoid carcinoma is reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2012). 4. The additional evidence received since the April 2006 rating decision is new and material, and the claim for service connection for bilateral hearing loss is reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2012). 5. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309(a), 3.385 (2012). 6. The criteria for service connection for tinnitus have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 7. The criteria for service connection for hypertension have not been met. 38 U.S.C.A. §§ 1110, 1116(f), 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 4.104, Diagnostic Code 7101, Note 1 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist After review of the claims file, the Board finds that VA has met all statutory and regulatory notice and duty to assist provisions in this case with respect to the issues herein decided. See 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, 3.326 (2012). Given the favorable disposition of the action here, which is not prejudicial to the Veteran, the Board need not assess VA's compliance with the VCAA in the context of the issues of whether new and material evidence has been submitted to reopen the Veteran's claims for entitlement to service connection for mucoepidermoid carcinoma and for bilateral hearing loss. See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92, 57 Fed. Reg. 49,747 (1992). The information contained in March and July 2008 letters satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Moreover, the Veteran was notified of regulations pertinent to the establishment of an effective date and disability rating in the March and July 2008 letters. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's service treatment records, service personnel records, VA medical treatment records, identified private medical records, and letters from the Veteran's private physicians have been obtained. Also, the Veteran was provided a VA audiological examination in September 2008. This examination and its associated report was adequate because, along with the other evidence of record, they provided sufficient information to decide the appeal and a sound basis for a decision on the Veteran's hearing loss and tinnitus claims. The examination report was based on examination of the Veteran by an examiner with appropriate expertise who reviewed the claims file. 38 C.F.R. § 3.159(c)(4) (2012); Barr v. Nicholson, 21 Vet. App. 303 (2007). A VA examination was not obtained for the claim of service connection for hypertension. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a Veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the Veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court of Appeals for Veterans Claims (Court) has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the Veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, regarding the Veteran's claimed hypertension, the evidence did not surpass the low threshold set by McLendon. Where the evidence does not establish that a disability may be associated with service, there is no need to obtain a medical opinion regarding any such nexus. As discussed below, the evidence does not establish that the Veteran's hypertension began in service, and there is no medical or other competent evidence suggesting a nexus between the Veteran's hypertension and service or any other such evidence that would warrant obtaining a medical nexus opinion. In this regard, the Federal Circuit has addressed the appropriate standard to be applied in determining whether an examination is warranted. In Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) and Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), the Federal Circuit held that while there must be "medically competent" evidence of a current disability, "medically competent" evidence is not required to indicate that the current disability may be associated with service. Colantonio, 606 F.3d at 1382; Waters, 601 F.3d at 1277. On the other hand, a conclusory generalized lay statement suggesting a nexus between a current disability and service (as in this case) would not suffice to meet the standards, as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. Waters, 601 F.3d at 1278-1279. Here, as the only evidence that the Veteran's claimed disability is related to military service is the conclusory generalized lay statements of the Veteran, which are unsupported by even speculative medical evidence. Accordingly, the Board finds that referral for a VA medical examination is not warranted. There is no indication in the record that any additional evidence relevant to the issues decided is available and not part of the claims 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, 543 (2006); see also Dingess/Hartman, 19 Vet. App. at 486. Also, in Bryant v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103(c)(2) requires that the Veterans Law Judge who conducts a hearing fulfill two duties to comply with the regulation. They consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. In this case, during the August 2011 Board personal hearing, the AVLJ fully explained the issues on appeal. The Veteran was assisted at the hearing by an accredited representative from the Veterans of Foreign Wars of the United States. The AVLJ and the representative asked questions regarding the nature and etiology of the Veteran's claimed hearing loss, tinnitus, and hypertension, specifically regarding their onset, the Veteran's noise exposure in service, and how the Veteran believed such disabilities were related to his service. In addition, the AVLJ sought to identify any pertinent evidence not currently associated with the claims file that might have been overlooked or was outstanding that might substantiate the claim, and specifically informed the Veteran of the type of evidence that would help substantiate his claims. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any prejudice in the conduct of the Board hearing. As such, the Board finds that, consistent with Bryant, the AVLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2), and that any error in notice provided during the Veteran's hearing constitutes harmless error. All of the evidence in the Veteran's claims file has been thoroughly reviewed. Although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence, and on what the evidence shows or fails to show with respect to the matters decided. The Veteran should not assume that pieces of evidence, not explicitly discussed herein, have been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). II. New and Material Evidence Pertinent procedural regulations provide that "[n]othing in [38 U.S.C.A. § 5103A] shall be construed to require [VA] to reopen a claim that has been disallowed except when new and material evidence is presented or secured, as described in [38 U.S.C.A. § 5108]." 38 U.S.C.A. § 5103A(f) (West 2002). Reopening a claim for service connection which has been previously and finally disallowed requires that new and material evidence be presented or secured since the last final disallowance of the claim. 38 U.S.C.A. § 5108; Evans v. Brown, 9 Vet. App. 273, 285 (1996); see also Graves v. Brown, 8 Vet. App. 522, 524 (1996). In the October 2008 rating decision, the RO addressed the claim for service connection for bilateral hearing loss on the merits. However, regardless of the RO's actions, the Board has a legal duty under 38 U.S.C.A. §§ 5108 and 7104 to address the question of whether new and material evidence has been received to reopen the claim for service connection. That matter goes to the Board's jurisdiction to reach the underlying claim and adjudicate the claim on a de novo basis. See Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996). New evidence means existing evidence not previously submitted to VA. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998), the United States Court of Appeals for the Federal Circuit (Federal Circuit) noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a claimant's injury or disability, even where it would not be enough to convince the Board to grant a claim. In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). In Elkins v. West, 12 Vet. App. 209 (1999), the Court of Appeals for Veterans Claims (Court) held the Board must first determine whether the appellant has presented new and material evidence under 38 C.F.R. § 3.156(a) in order to have a finally denied claim reopened under 38 U.S.C.A. § 5108. Then, if new and material evidence has been submitted, the Board may proceed to evaluate the merits of the claim, but only after ensuring that VA's duty to assist has been fulfilled. See Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999). The Court recently held that the law should be interpreted to enable reopening of a claim, rather than to preclude it. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The RO denied service connection for mucoepidermoid carcinoma in March 2005 and denied service connection for carcinoma of the jaw and bilateral hearing loss in April 2006. Those rating decisions were not appealed, and no new evidence pertinent to either claim was received by VA within one year from the date that the RO mailed notice of either determination to the Veteran. Furthermore, VA has not received or associated with the claims file any relevant official service department records that existed and had not been associated with the claims file at the time of either decision. Therefore, the March 2005 and April 2006 rating decisions are final. 38 U.S.C.A. § 7105 (West 2002), 38 C.F.R. §§ 3.104, 20.302, 20.1103. See also 38 C.F.R. § 3.156(b), (c). The basis of the prior final denial of the claim for mucoepidermoid carcinoma was the RO's finding that no diagnosis of mucoepidermoid carcinoma was of record. The basis of the prior final denial of the claim for bilateral hearing loss was the RO's finding that there was no evidence that the Veteran's claimed condition was caused by or related to service. Thus, in order for the Veteran's claims to be reopened, evidence must have been added to the record since those rating decisions that addresses those bases. Evidence submitted and obtained since the March 2005 and April 2006 rating decisions includes July 2009 statements from the Veteran's private treating physicians, Dr. S.S. and Dr. D.C., indicating that the Veteran clearly had noise-induced sensorineural hearing loss, and that his sound exposure history in the military could be a causative factor for much of his hearing loss. It also includes November 1997 records reflecting surgical treatment for mucoepidermoid cancer, and an August 2011 letter from Dr. S.S. indicating that, in November 1997, Dr. S.S. removed a large, left oral cavity cancer that proved to be a mucoepidermoid carcinoma, which was a rare, minor salivary gland tumor. Without addressing the merits of this evidence, the Board finds that it addresses the issues of whether the Veteran has any current disability involving mucoepidermoid carcinoma and whether bilateral hearing loss is related to service. Justus, 3 Vet. App. at 512-13. Thus, this evidence is both "new," as it has not previously been considered by VA, and "material," as it addresses an unestablished facts and it raises a reasonable possibility of substantiating each of the Veteran's claims. The Board thus finds that new and material evidence has been submitted to reopen the issues of entitlement to service connection for mucoepidermoid carcinoma and for bilateral hearing loss since the March 2005 and April 2006 rating decisions. On this basis, the issues of entitlement to service connection for mucoepidermoid carcinoma and for bilateral hearing loss are reopened. III. Service Connection Law and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; 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, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for certain chronic diseases, such as hypertension and organic disease of the nervous system, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within a prescribed period following discharge from service; the presumptive period for arthritis is one year. 38 C.F.R. §§ 3.307, 3.309(a). When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim for such diseases. 38 C.F.R. §§ 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The provisions of 38 C.F.R. § 3.385 do not require that hearing loss be shown as defined in that regulation at the time of separation from service, if there is sufficient evidence to demonstrate a relationship between the Veteran's service and his current disability. Hensley v. Brown, 5 Vet. App. 155 (1993). Absent affirmative evidence to the contrary, there is a presumption of exposure to herbicides (to include Agent Orange) for all veterans who served in the Republic of Vietnam during the Vietnam Era (the period beginning on January 9, 1962, and ending on May 7, 1975). 38 U.S.C.A. § 1116(f) and 38 C.F.R. § 3.307(a)(6)(iii). If a veteran was exposed to a herbicide agent (to include Agent Orange) during active service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: AL amyloidosis, chloracne or other acneform diseases consistent with chloracne, type II diabetes, Hodgkin's disease, ischemic heart disease, all chronic B-cell leukemias, 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 sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). Effective on August 31, 2010, VA amended 38 C.F.R. § 3.309(e) to add hairy cell leukemia and other chronic B-cell leukemias, Parkinson's disease and 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) to the list of diseases associated with exposure to certain herbicide agents. The intended effect of this amendment is to establish presumptive service connection for these diseases based on herbicide exposure. The final rule is applicable to claims received by VA on or after August 31, 2010, and to claims pending before VA on that date. Note 3 indicates that, for purposes of this section, the term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. 38 C.F.R. § 3.309(e). The final rule is applicable to claims received by VA on or after August 31, 2010, and to claims pending before VA on that date. Additionally, VA will apply this rule in readjudicating certain previously denied claims as required by court orders in Nehmer v. Department of Veterans Affairs, No. CV-86-6161 TEH (N.D. Cal.). The Secretary of Veterans Affairs has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. VA has issued several notices in which it was determined that a presumption of service connection based upon exposure to herbicides used in Vietnam should not be extended beyond specific disorders, based upon extensive scientific research. See, e.g., 68 Fed. Reg. 27630-27641 (May 20, 2003); 67 Fed. Reg. 42600 (June 24, 2002); 66 Fed. Reg. 2376 (Jan. 11, 2001); 64 Fed. Reg. 59232 (Nov. 2, 1999). Notwithstanding the presumption, service connection for a disability claimed as due to exposure to Agent Orange may be established by showing that a disorder resulting in disability or death was in fact causally linked to such exposure. See Brock v. Brown, 10 Vet. App. 155, 162-64 (1997); Combee v. Brown, 34 F.3d 1039, 1044 (Fed. Cir. 1994), citing 38 U.S.C.A. § 1113(b) and 1116 and 38 C.F.R. § 3.303. With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both 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"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a Veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Routen, 10 Vet. App. 183. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). In determining whether service connection is warranted for a disability, 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 the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Analysis In this case, service treatment records reflect no diagnoses, findings, or complaints of hearing loss or hypertension. In February 1971, the Veteran complained of ringing in his right ear with no pain or dizziness; it was noted that he had had a cold, and the impression was tinnitus. Service treatment records contain no further complaints or findings related to tinnitus. Service examinations dated in August 1965, February 1966, June 1966, July 1968, November 1969, and October 1971, as well as separation examination in February 1972, reflect consistently normal clinical evaluations of the ears and vascular system, with no hearing loss, tinnitus, or hypertension diagnosed or reported by the Veteran; in October 1971 and on February 1972 separation examination, the Veteran specifically reported not having and having never had any ear trouble, running ears, hearing loss, or high or low blood pressure. The Veteran's blood pressure readings in February 1966 and June 1966, were 120/60 and 122/78, respectively; in July 1968, November 1969, and October 1971, it was noted to have been 106/74, 130/82, and 118/72 sitting, 110/66, 130/78, and 122/76 recumbent, and 130/74, 132/90, and 138/82 standing, respectively. On February 1972 separation examination, the Veteran's blood pressure was measured as 124/82. Audiometric testing was performed several times during the Veteran's period of service. Service department audiometric readings prior to October 31, 1967, must be converted from American Standards Association (ASA) units to International Standard Organization (ISO) units. On audiological testing, at 500, 1000, 2000, and 4000 Hertz, respectively, pure tone thresholds, in decibels, were, 0, 0, 0, and 5 in the right ear and 0, 0, 0 and 10 in the left ear in February 1965, and 0, 0, 0, and 0 in each ear in August 1965 and February 1966; converted from ASA units to ISO units, they were 15, 10, 10, and 10 in the right ear and 15, 10, 10, and 15 in the left ear in February 1965, and 15, 10, 10, and 5 in each ear in August 1965 and February 1966. On audiological testing, at 500, 1000, 2000, and 4000 Hertz, respectively, pure tone thresholds, in decibels, were, 0, 0, 0, and 15 in the right ear and 0, 0, 0, and 15 in the left ear in July 1968; 0, 0, 0, and 5 in the right ear and 0, 0, -5, and 5 in the left ear in November 1969; 0, 0, 0, and 5 in the right ear and 0, 0, 0, and 20 in the left ear in October 1971; and 5, 0, 0, and 10 in the right ear and 5, 0, 0, and 20 in the left ear on February 1972 separation examination. Service personnel records reflect that the Veteran served as an electrical engineer and intercept equipment repair technician, including in the Republic of Vietnam from September 1966 to April 1968. A performance evaluation dated in January 1968 reflects that his duties included supervising and coordinating all repair and maintenance of complex electronic equipment within an aviation company that had organic single engine and multiengine fixed wing aircraft in support of the counterinsurgency effort in the Republic of Vietnam. There is no indication of high blood pressure or any diagnosis of hypertension prior to VA treatment records beginning in March 2003. In March 2003, the Veteran's blood pressure was noted to have been 139/87. In August 2004, a diagnosis of hypertension was noted. The earliest indication in the record of any hearing loss problems is a November 2005 VA treatment note reflecting that the Veteran was seen for a hearing evaluation and reported a history of military flight noise. He reported an intermittent ringing in both ears that had occurred approximately once a week, and stated that this had persisted for three or four years. Pure tone thresholds were within normal limits in the right ear through 2000 Hertz, with a mild sensorineural hearing loss at 3000 Hertz and moderately severe to profound high frequency sensorineural hearing loss. The left ear pure tone thresholds were normal through 2000 Hertz, with a moderate to moderately severe high frequency sensorineural hearing loss. Word recognition ability was excellent in both ears. The Veteran originally filed a claim for service connection for hearing loss in November 2005, shortly after the VA treatment date. He asserted at that time that his hearing was impaired from exposure to jet aircraft noise while stationed in Vietnam, and that, based on recent VA hearing tests, he required hearing assistance. The report of a September 2008 VA audiological examination reflects that the examining audiologist reviewed the claims file and noted that the service treatment records included eight hearing tests dated from February 1965 to January 1972, which all indicated thresholds in the normal range bilaterally. The examiner noted that there was a report in February 1971 of right ear tinnitus associated with an upper respiratory infection. The Veteran's chief complaints were difficulty hearing and constant, bilateral ringing tinnitus. The Veteran stated that the problems began while in service and attributed the problems to exposure to the aircraft noise while on the flight line without hearing protection in Vietnam. The Veteran stated that he was a teacher, and that his hearing problem resulted in difficulty hearing students and the other instructor during class. On audiological testing, pure tone thresholds in the right ear, in decibels, were 15, 20, 30, 50, and 75 at 500, 1000, 2000, 3000, and 4000 Hertz, respectively; pure tone thresholds in the left ear, in decibels, were 10, 15, 25, 50, and 55 at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. Speech discrimination scores using the Maryland CNC list were noted to be 98 percent in the right ear and 96 percent in the left ear. The VA examiner noted that the service treatment records included a note indicating that the Veteran reported right ear tinnitus related to a cold that he had at the time, and that at that time the Veteran reported that his tinnitus and hearing loss began while in service, but that on his November 2005 hearing test he reported intermittent tinnitus that began around 2000-2002. The examiner also noted that the Veteran, on examination that day, reported no civilian noise exposure, but that on the November 2005 visit reported civilian exposure to chainsaws, firearms, and motorcycle noise. The examiner explained that one episode of tinnitus associated with a cold was not considered an indication of tinnitus due to acoustic trauma. The examiner further stated that there was no evidence of hearing loss while in the military. It was the examiner's opinion, therefore, that the Veteran's hearing loss and tinnitus were not related to service. A statement dated in July 2009 from the Veteran's private physician, Dr. S.S., reflects that the Veteran had been complaining of increasing hearing loss and that, by examination and audiogram, he clearly had noise-induced hearing loss. A statement from another private physician, Dr. D.C., dated in July 2009, indicated that the Veteran complained of hearing loss and ringing in the ears that was rather constant, that he had had very little recreational exposure to loud sounds over the years, but was in the military, was on the flight line frequently, fired weaponry, and was exposed to loud sounds. Dr. D.C. stated that the Veteran had high frequency sensorineural hearing loss in each ear, a little worse in the right ear, and that Dr. D.C. could not rule out or rule in all causes of such loss. Dr. D.C. stated that one might conclude that the Veteran's sound exposure history in the military did not affect his hearing, but that the exposure he had certainly could be causative for a lot of his high frequency loss. During the August 2011 Board hearing, the Veteran testified that he spent his six-year service career working with Army aviation projects, that during his one and a half year tour in Vietnam he was located on the flight line, and that there was a lot of aircraft noise that he was exposed to. He testified that he experienced noise-induced pain working on the flight line, that the Army did not provide hearing protection, and that he was constantly subjected to loud noise in service. He also testified that he had had civilian noise exposure but always used hearing protection as needed, that the only type of motorcycle he owned was a BMW, and that the noise level of a BMW motorcycle was less than most cars. He stated that he always used ear protection when exposed to noise from firearms, chainsaws, and those types of things, and personally owned several noise protectors. He testified that his hearing was getting to the point where he could not perform his job. He also testified that he did not recollect any hearing loss symptoms service, that he never had his hearing checked because it was not an issue, and that it had mostly manifested itself over the last seven or eight years. Regarding his tinnitus, the Veteran testified that he did not really know when he first noticed ringing in his ears, that it had been a while back, but that he really became aware of it the first time he had a hearing test. He stated that he really had not thought about it until he was asked about it, but that he had had it but did not notice it, that this was probably about five years before, and that since that time he had really noticed it. Regarding his hypertension, he testified that he had been taking blood pressure medication for probably about six to eight years, that he had no episodes of hypertension on active duty that he knew of, but the he felt that his hypertension was related to military service because exposure to Agent Orange is the only thing that could have caused his hypertension. Considering the pertinent evidence in light of the governing legal authority, the Board finds that the Veteran's service connection claims must be denied. Regarding the Veteran's claims for hearing loss and tinnitus, the Veteran is competent to describe being exposed to loud noise and is competent to describe observable symptoms such as ringing in the ears or decreased hearing. A lay person is competent to testify as to observable symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (a veteran is competent to testify that he experienced ringing in his ears in service and had experienced ringing in his ears ever since service). The Veteran's lay statements are found to be credible as they have been consistent and are confirmed by the circumstances of his service. The service records show that the Veteran's in-service military occupation specialty was electrical engineer and intercept equipment repair technician and he served in the Republic of Vietnam from September 1966 to April 1968. The Board finds that the Veteran's assertion of exposure to very loud noise in service, including from aircraft, is likely credible. However, even assuming the credibility of this assertion, the evidence reflects that neither bilateral hearing loss nor tinnitus began during or is related to service. The Board finds that the weight of the competent and credible evidence establishes that the Veteran did not experience chronic hearing loss or tinnitus symptoms in service and he did not experience continuous post service symptoms of a bilateral hearing loss and tinnitus. See 38 C.F.R. § 3.303(b). Therefore, the criteria for presumptive service connection pursuant to 38 C.F.R. § 3.303(b) for chronic in service symptoms and continuous post service symptoms are not met. The weight of the evidence shows that the hearing loss and tinnitus did not begin in service and first manifested many years after service. The Veteran is competent to report matters within his own personal knowledge. See Layno, 6 Vet. App. at 469. However, during the Veteran's August 2011 Board hearing, he did not assert that he had had hearing loss or tinnitus since service, but rather testified that he did not recollect any hearing loss symptoms in service and never had his hearing checked because it was not an issue, that hearing loss had mostly manifested itself over the last seven or eight years, and that he had first noticed tinnitus about five years before. Also, in October 1971 and on February 1972 separation examination, the Veteran specifically reported not having and having never had any ear trouble, running ears, or hearing loss. While in February 1971 the Veteran complained of ringing in his right ear in connection with a cold, service treatment records contain no further complaints or findings related to tinnitus. Furthermore, the earliest indication in the record of any hearing loss problems is a November 2005 VA treatment note, dated more than 30 years after the Veteran's separation from service, reflecting that the Veteran was seen for a hearing evaluation and reported an intermittent ringing in both ears that had occurred approximately once a week, and stated that this had persisted for three or four years. While on September 2008 VA examination the Veteran stated that difficulty hearing and constant, bilateral tinnitus began while in service, this assertion is not credible in light of the evidence noted above, including the Veteran's own contradictory statements regarding the onset of his hearing loss and tinnitus. The Board finds that the weight of the competent and credible evidence establishes that the Veteran did not experience chronic bilateral hearing loss or tinnitus symptoms in service and did not experience continuous post service symptoms of a bilateral hearing loss or tinnitus. See 38 C.F.R. § 3.303(b). Therefore, the criteria for presumptive service connection pursuant to 38 C.F.R. § 3.303(b) for chronic in service symptoms and continuous post service symptoms are not met. Service treatment records, including several audiometric evaluations, do not reflect a hearing loss disability for VA purposes in service, and there is no evidence of any such disability within one year of the Veteran's service. Therefore, the presumptive service connection provisions for chronic diseases under 38 C.F.R. §§ 3.307 and 3.309(a) are not applicable in this case. Finally, the Board finds that the weight of the evidence demonstrates that the bilateral hearing loss and tinnitus are not caused by any in-service event or injury and are not otherwise related to service. There is somewhat conflicting medical opinion evidence regarding the relationship between the Veteran's hearing problems and service. When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). 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). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The Veteran submitted medical opinions from Dr. S.S. and Dr. D.C. in support of his claims. In the July 2009 statements, Dr. S.S. and Dr. D.C. indicated that the Veteran had noise-induced hearing loss and that the Veteran's military noise exposure "could be" causative for a lot of his high frequency hearing loss. The Board finds that the private medical opinions are of diminished probative value given their equivocality with respect to the relationship of hearing problems to service, and the lack of any explanation of why any current hearing loss would be related to service more than 35 years prior. The Court has held that medical opinions that are speculative, general, or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993). See Bloom v. West, 12 Vet. App. 185, 187 (1999) (A medical statement using the term "could," or in the moving party's case, "may" or "possibly," without supporting clinical data or other rationale, is too speculative in order to provide the degree of certainty required for medical nexus evidence). See also Obert v. Brown, 5 Vet. App. 30, 33 (1993) (a medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish medical nexus); and Warren v. Brown, 6 Vet. App. 4, 6 (1993) (doctor's statement framed in terms such as "could have been" is not probative). The most probative evidence on the question of whether hearing loss or tinnitus is related to service is the opinion of the September 2008 VA audiological examiner, in which the examiner opined that the Veteran's hearing loss and tinnitus were not related to service. The Board finds the examiner's opinion to be persuasive. The examiner has appropriate expertise and he considered the Veteran's medical history and lay statements, reviewed the claims folder including the service treatment records, and fully examined the Veteran. Factors for assessing the probative value of a medical opinion are the examiner's access to the claims file and the thoroughness and detail of the opinion. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The medical opinion is based on sufficient facts and data. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Also, unlike Dr. S.S. or Dr. D.C., the VA examiner provided an unequivocal opinion based on a review of the claims file with plausible explanations for his opinions. Furthermore, such explanations, including that tinnitus associated with a cold was not considered an indication of tinnitus due to acoustic trauma and the Veteran's inconsistent statements regarding the onset of tinnitus and his post-service noise exposure given in November 2005 and on September 2008 examination, are consistent with record. Thus, the Board finds that the opinion evidence provided by the September 2008 VA examiner outweighs that given by Dr. S.S. and Dr. D.C. The Board acknowledges that, while service treatment records do not reflect a hearing loss disability for VA purposes, the Veteran's audiometric test results show some variation while in service. In this regard, such audiometric test results were specifically noted, considered, and discussed by the September 2008 VA examining audiologist's report, in which he nonetheless opined that hearing loss and tinnitus were not related to service. The Board recognizes that the Veteran might believe that his hearing loss or tinnitus are related to in-service noise exposure, and the Veteran's assertions during his August 2011 Board hearing that, while he had had civilian noise exposure such as from firearms and chainsaws, he always used hearing protection as needed, and that the noise level of his BMW motorcycle was less than most cars. As noted, the Veteran, as a lay person, is competent to describe observable symptoms such as decreased hearing or ringing in the ears. Although lay persons are competent to provide opinions on some medical issues, see Kahana, 24 Vet. App. at 435, as to the specific issue in this case, an opinion as to the etiology of hearing loss or tinnitus falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377 n.4 (lay persons not competent to diagnose cancer). Some medical issues require specialized training for a determination as to diagnosis and causation; therefore such issues are not susceptible of lay opinions on etiology. A lay person may speak as to etiology in some limited circumstances in which nexus is obvious merely through lay observation. Jandreau, 492 F.3d 1372. However, to the extent that the Veteran might be competent at all to relate his hearing loss or tinnitus to noise he experienced during his period of service, such an opinion is heavily outweighed by the objective medical opinion of the September 2008 VA examiner that, for the reasons discussed above, the Board finds persuasive in this case. Regarding the Veteran's claim for hypertension, the Board finds that the weight of the competent and credible evidence establishes that the Veteran did not experience chronic hypertension symptoms in service and he did not experience continuous post service symptoms of hypertension. See 38 C.F.R. § 3.303(b). The Board finds that the weight of the competent and credible evidence establishes that hypertension was not diagnosed within one year of the Veteran's service. The record does not reflect, and the Veteran has not contended, that hypertension began in service or within a year of service. While service treatment records reflect varying blood pressure readings, they do not reflect readings indicating hypertension for VA purposes; hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days, and for VA compensation purposes, hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. Also, in October 1971 and on February 1972 separation examination, the Veteran specifically reported not having and having never had high or low blood pressure, and no diagnosis of hypertension was noted in the record in service or until more than 30 years after service. Furthermore, during his August 2011 Board hearing, the Veteran testified that that he had been taking blood pressure medication for probably about six to eight years and that he had had no episodes of hypertension on active duty that he knew of. Thus, the presumptive service connection provisions for chronic diseases under 38 C.F.R. §§ 3.307 and 3.309(a) do not apply. Rather, as reflected in his August 2011 testimony, the Veteran asserts that he has hypertension as a result of exposure to Agent Orange in service. Hypertension is not a disease listed under 38 C.F.R. § 3.309(e), and, therefore, the Veteran's hypertension is not presumed to have been the result of in-service Agent Orange exposure pursuant to 38 U.S.C.A. § 1116(f) and 38 C.F.R. §§ 3.307(a)(6)(iii) and 3.309(e). While service connection for hypertension may be established by showing that it was in fact causally linked to Agent Orange exposure, the Veteran's only evidence is his bare assertion that Agent Orange is the only thing that could have caused his hypertension. There is no medical evidence or further details of record of how the Veteran's hypertension might be related to Agent Orange, and neither the Veteran nor his representative has offered any such evidence whatsoever. There is no medical evidence of record which medically relates the post-service diagnosis of hypertension to active service. The Veteran himself has attempted to relate the hypertension to herbicide exposure. As noted, the Veteran, as a lay person, is competent to describe observable symptoms such as pain. Although lay persons are competent to provide opinions on some medical issues, see Kahana; supra; as to the specific issue in this case, an opinion as to the etiology and onset of hypertension falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377 n.4 (lay persons not competent to diagnose cancer). Some medical issues require specialized training for a determination as to diagnosis and causation; therefore such issues are not susceptible of lay opinions on etiology. Therefore, the Board finds that the weight of the evidence demonstrates that the hypertension is not caused by any in-service event or injury and is not otherwise related to service including herbicide exposure in service. Accordingly, the Board finds that the claims for service connection for bilateral hearing loss, tinnitus, and hypertension must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claims, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 53-56. ORDER New and material evidence having been received, the Veteran's claim for entitlement to service connection for mucoepidermoid carcinoma is reopened and, to that extent only, the appeal is granted. New and material evidence having been received, the Veteran's claim for entitlement to service connection for bilateral hearing loss is reopened and, to that extent only, the appeal is granted. Service connection for bilateral hearing loss is denied. Service connection for tinnitus is denied. Service connection for hypertension is denied. REMAND The Veterans Claims Assistance Act of 2000 (VCAA), specifically provides that the duty to assist includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002). The most recent VA examination of the Veteran's right knee is dated in July 2008, and during his August 2011 Board hearing, he testified that his right knee disability had worsened in severity since that examination. VA treatment records reflect that the Veteran had an arthroscopic meniscectomy in March 2011. Because of the evidence of possible worsening since the last examination in 2008, a new examination is needed to determine the severity of the service-connected right knee disability. Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). Also, the claims file reflects that the Veteran had been receiving treatment from the VA Central Arkansas Healthcare System. Records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). The most recent VA treatment records in the claims file are dated in March 2012. Accordingly, on remand, the RO or AMC should obtain any pertinent records from the VA Central Arkansas Healthcare System dated from March 2012 to the present. Furthermore, in response to the Veteran's March 2008 claim to reopen his previously denied claim for service connection for mucoepidermoid carcinoma, the RO issued a rating decision in October 2008, and subsequently a statement of the case in August 2010 and supplemental statement of the case in July 2011. However, in each if these adjudications, the Veteran's claim was denied on the basis that new and material evidence had not been received to reopen his previously denied claim of entitlement to service connection for mucoepidermoid carcinoma, which, as noted above, was denied on the basis that the Veteran had not shown a diagnosis of this disorder. Thus, the RO has not yet adjudicated the reopened claim of entitlement to service connection for mucoepidermoid carcinoma on its merits. Consideration of the Veteran's claim by the Board in the first instance, without initial RO consideration of the matter, would deprive the Veteran of the "means to obtain 'one review on appeal to the Secretary.'" See Disabled American Veterans (DAV) v. Secretary of Veterans Affairs, 327 F. 3d 1339, 1347 (Fed. Cir. 2003); 38 U.S.C.A. § 7104(a) (West 2002). Therefore, the matter of entitlement to service connection for mucoepidermoid carcinoma must be remanded to the RO for adjudication. The RO should complete any necessary development for this claim. Accordingly, the case is REMANDED for the following action: 1. Obtain all outstanding VA medical records related to the Veteran's right knee strain with degenerative joint disease and mucoepidermoid carcinoma from the VA Central Arkansas Healthcare System, dated from March 2012 to the present. All records and/or responses received should be associated with the claims file. 2. Schedule the Veteran for a VA examination to ascertain and evaluate the current level of severity of his right knee strain with degenerative joint disease. The claims folder should be made available to the examiner in conjunction with the examination. Any medically indicated special tests should be accomplished. The examiner should report the range of motion in the right knee in degrees and indicate at what point pain begins. The examiner should determine whether the right knee disability is manifested by painful motion, weakened movement, excess fatigability, or incoordination. These determinations should be expressed in terms of the degree of additional range-of-motion loss due to any painful motion, weakened movement, excess fatigability or incoordination. The examiner should indicate whether the right knee disability results in functional loss in terms of limitations in the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The examiner should report whether there is recurrent subluxation or lateral instability of the right knee, and if present, express an opinion as to the severity of such subluxation or lateral instability (slight, moderate, or severe). An X-ray examination of the right knee should be performed. The examiner should report whether the functional impairment due to the right knee disability is severe, moderate or slight. If the examiner is unable to provide the requested information with any degree of medical certainty, the examiner should indicate that. The examiner should set forth the complete rationale underlying any conclusions drawn or opinions expressed, to include, as appropriate, citation to specific evidence in the record, in a legible report. 3. Complete any development deemed necessary for the claim of entitlement to service connection for mucoepidermoid carcinoma. 4. After completing the above development, readjudicate the issues of entitlement to an increased rating for the right knee disability and service connection for mucoepidermoid carcinoma. If any benefit sought remains denied, provide an additional supplemental statement of the case to the Veteran and his representative, and return the appeal to the Board for appellate review, after the Veteran has had an adequate opportunity to respond. The Veteran 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 of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ C. L. KRASINSKI Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs