Citation Nr: 1329752 Decision Date: 09/17/13 Archive Date: 09/25/13 DOCKET NO. 06-27 506 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a gastrointestinal disorder, claimed as ulcerative proctitis, and to include as secondary to medications prescribed for service-connected coronary artery disease (CAD). 2. Entitlement to service connection for right kidney disorder, to include renal cell carcinoma, claimed as due to exposure to Agent Orange or benzene chemicals. 3. Entitlement to service connection for hemorrhoids, to include as secondary to medications prescribed for service-connected CAD and ulcerative proctitis. 4. Entitlement to service connection for hypertension, to include as secondary to service-connected CAD and exposure to Agent Orange and benzene chemicals. REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Carole Kammel, Counsel INTRODUCTION The Veteran served on active duty from March 1969 to December 1970, to include service in the Republic of Vietnam (RVN). These matters are before the Board of Veterans' Appeals (Board) from an October 2004 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. By that rating action, the RO, in part, denied service connection for ulcerative proctitis; renal cell carcinoma, right kidney; internal hemorrhoids; and, hypertension. The Veteran appealed this rating action to the Board. In August 2007, the Veteran testified at a hearing at the RO before a Veterans Law Judge (VLJ) who subsequently retired from the Board and a copy of the hearing transcript has been added to the record. In May 2013, the Veteran was provided with an opportunity to request another Board hearing before a different Veterans Law Judge. In a June 2013 statement, the Veteran indicated that he no longer desired a hearing before a VLJ. Thus, he will not be afforded another hearing before a different VLJ. See 38 U.S.C.A. § 7107 (West 2002); 38 C.F.R. §§ 20.707, 20.717 (2012). The matters on appeal were most recent before the Board in January 2012. At that time, the Board remanded the matters to the RO for additional development. The requested development has been completed and the matters have returned to the Board for further appellate consideration. In a June 2009 written statement and May 2012 typed statement, the Veteran raised informal claims of entitlement to a total disability evaluation based on individual unemployability (TDIU) due to service-connected disabilities and whether new and material evidence had been received to reopen a previously denied claim for service connection for tinnitus. (See VA Form 21-4138, Statement in Support of Claim and typographed statement to VA, dated and signed by the Veteran in June 2009 and May 2012, respectively). These issues have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. In a July 2012 written argument to VA, the Veteran, through his representative raised the argument that his ulcerative proctitis and hemorrhoids were secondary to medications prescribed for his service-connected CAD. The Veteran also maintained that his hemorrhoids were secondary to his ulcerative proctitis. (See Veteran's representative's written argument to VA, pages (pgs.) 2, 3)). The RO has not developed or adjudicated the secondary component of the Veteran's claims for service connection for ulcerative proctitis and hemorrhoids. In the case of Robinson v. Mansfield, 21 Vet. App. 545 (2007) the United States Court of Appeals for Veterans Claims (Court) cited Roebuck v. Nicholson, 20 Vet. App. 307, 313 (2006), which held that "although there may be multiple theories or means of establishing entitlement to a benefit for a disability, if the theories all pertain to the same benefit for the same disability, they constitute the same claim." Thus, the Board has expanded the claims for service connection for ulcerative proctitis and hemorrhoids to include the secondary service connection theories advanced by the Veteran, as noted on the title page. Finally, as noted by the Veteran's representative in the above-cited July 2012 written argument, the Veteran waived additional evidence that he submitted to VA after the RO's issuance of a supplemental statement of the case that addressed the issues on appeal in May 2012. Thus, a remand to have the RO initially consider this evidence in the first instance is not necessary. 38 C.F.R. § 20. 1304 (2012). Notwithstanding the foregoing, the Board finds, for reasons that are outlined in more detail below, that a remand is necessary on the claims for service connection for hemorrhoids, to include as secondary to medications prescribed for service-connected CAD and ulcerative proctitis and service connection for hypertension, to include as secondary to in-service exposure to Agent Orange and benzene chemicals. The issues of entitlement to service connection for hemorrhoids, to include as secondary to medications prescribed for service-connected coronary artery disease and ulcerative proctitis and entitlement to service connection for hypertension, to include as secondary to service-connected CAD and in-service exposure to Agent Orange and benzene chemicals 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 objective medical evidence is in equipoise as to whether the Veteran's current gastrointestinal disorder, claimed as ulcerative proctitis, was aggravated by medications prescribed for his service-connected CAD. 2. The Veteran had active military service in the RVN; thus, his exposure to Agent Orange is presumed. 3. The objective medical evidence is in equipoise as to whether his current renal cell carcinoma was caused by exposure to Agent Orange and benzene chemicals. CONCLUSIONS OF LAW 1. The criteria for service connection for a gastrointestinal disorder, claimed as ulcerative proctitis, as secondary to medications prescribed for service-connected CAD, have been met. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.159; 3.310 (2012). 2. The criteria for service connection for renal cell carcinoma, to include as due to Agent Orange and benzene chemicals have been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The Board's decision herein to grant service connection for ulcerative proctitis as secondary to medications prescribed for service-connected CAD and renal cell carcinoma as secondary to in-service Agent Orange and benzene chemicals constitutes a full grant of these benefits. Therefore, no further action is necessary to comply with the Veterans Claims Assistance Act of 2000 and implementing regulations with respect to these claims decided herein. II. Legal Criteria Service connection-general criteria 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, 1131; 38 C.F.R. § 3.303(a). 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). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). In addition, certain chronic diseases, such as peptic ulcers (gastric or duodenal) and malignant tumors, may be presumed to have been incurred during service if they become manifested to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309; see also 67 Fed. Reg. 67792 -67793 (Nov. 7, 2002). In this case, the presumption does not apply because there is no medical evidence that the Veteran manifested a peptic ulcer or malignant tumor of the right kidney to a compensable degree within one year of service discharge in December 1970. See 38 C.F.R. §§ 3.307, 3.309. The second and third elements may be established by showing continuity of symptomatology. Continuity of symptomatology may be shown by demonstrating "(1) that a condition was 'noted' during service or any applicable presumption period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology." Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); see also Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). However, the Federal Circuit recently held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic 38 C.F.R. § 3.309(a), such as a peptic ulcers and malignant tumors. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In order to prevail on the issue of entitlement to secondary service connection, there must be: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence, generally medical, establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). Secondary service connection-criteria Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. If there is at least an approximate balance of positive and negative evidence regarding any issue material to the claim, the claimant shall be given the benefit of the doubt in resolving each such issue. 38 U.S.C.A. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. §§ 3.102. On the other hand, if the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. III. Merits Analysis (i) Gastrointestinal Disorder, claimed as Ulcerative Proctitis The Veteran seeks service connection for a gastrointestinal disorder, claimed as ulcerative proctitis, to include as secondary to medications (e.g., aspirin and Plavix) prescribed for his service-connected CAD. There is only one opinion that addresses the secondary service connection component of the Veteran's claim and it is supportive of the claim. In an June 2012 statement, J. T., M. D., M. P. H., a specialist in toxicology and occupational and environmental medicine, who had extensively interviewed the Veteran in April 2012 and provided an opinion that his ulcerative colitis was not caused by in-service exposures, concluded that the Veteran's intestinal bleeding and diarrhea from his ulcerative proctitis was with greater than 50 percent worsened by the blood thinning medications, aspirin and Plavix, prescribed for his CAD This opinion is supportive of the Veteran's claim for ulcerative proctitis as secondary to medications, namely aspirin and Plavix, prescribed for his service-connected CAD. Recognition is given to the fact that the opinion from Dr. J. T did not provide any rationale. There are other means by which a physician can become aware of critical medical facts, notably by treating the claimant. Dr. J. T. had extensively interviewed the Veteran in April 2012 and provided a complete recitation of his service and post-service medical history, as well as a thorough review of medical literature. To this end, an internet article, submitted by the Veteran and received by the RO in June 2012, documents the side effects of aspirin, such as gastrointestinal bleeding. (See http://sideeffectz.com/aspirinsideeffects). While not clearly articulated, J. T., M. D.'s opinion is supported by medical studies and literature, and by that basis alone his opinion is found to be probative. There is also no other evidence in the record that weighs against Dr. J. T.'s positive opinion. Thus, although Dr. J. T.'s June 2012 opinion is of diminished value, given its lack of rationale, it nevertheless places the weight of the evidence in the Veteran's favor, and at least places the evidence in equipoise. Service connection for gastrointestinal disorder, which may include ulcerative proctitis as well as diarrhea and intestinal bleeding, as secondary to medications prescribed for service-connected CAD is granted. Further, as this claim is being granted, the Board finds that there would be no useful purpose in addressing the theories of direct or presumptive service connection. (ii) Right Kidney Disorder, to include renal cell carcinoma The Veteran seeks service connection for a right kidney disorder, to include renal cell carcinoma, to include as due to in-service exposure to Agent Orange and benzene chemicals. For purposes of establishing service connection for a disability resulting from exposure to an herbicide agent, a veteran who, during active military, naval, or air service, served in the Republic of Vietnam between January 1962 and May 1975, shall be presumed to have been exposed during such service to an herbicide agent, absent affirmative evidence to the contrary demonstrating that a veteran was not exposed to any such agent during service. 38 U.S.C.A. § 1116(f). The term "herbicide agent" means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the Vietnam area. The diseases listed at 38 C.F.R. § 3.309(e), which include prostate cancer, shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within one year, after the last date on which the Veteran was exposed to an herbicide agent during active service. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a)(6)(ii). If a Veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected even though there is no record of such disease during service: chloracne or other acneform disease consistent with chloracne, Type 2 diabetes, Hodgkin's disease, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx or trachea), and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). The diseases listed in 38 C.F.R. § 3.309(e) for which service connection is presumptively granted on the basis of exposure to herbicides were amended to add AL amyloidosis. See 74 Fed. Reg. 21, 258 (May 7, 2009); see also 38 C.F.R. § 3.307(a)(6)(ii). In addition, this regulation was recently amended to allow such presumptive service connection to be granted for ischemic heart disease, Parkinson's disease and hairy cell leukemia and other chronic B-cell leukemias. See 75 Fed. Reg. 53, 202 (August 31, 2010). However, VA has determined that there is no positive association between exposure to herbicides and any other condition for which it has not specifically determined that a presumption of service connection is warranted. See 59 Fed. Reg. 341-46 (Jan. 4, 1994); see also 61 Fed. Reg. 57,586 -57,589 (Nov. 7, 1996); 72 Fed. Reg. 32,345-32,407 (June 12, 2007). The Veteran's claimed renal disability, renal carcinoma, is not listed among the presumptive diseases for which service connection may be granted on the basis of exposure to herbicides under 38 C.F.R. § 3.309(e). In the absence of a diagnosed disease for which the Agent Orange presumption applies, 38 C.F.R. § 3.307(a)(6)(iii) is not applicable, and the Veteran's claim of service connection for a skin disability can be asserted on a direct service connection basis. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). For reasons that are outlined in more detail below, the Board will resolve doubt in the Veteran's favor and grant service connection for a renal cell carcinoma, to include as due to in-service Agent Orange and benzene chemicals. As to the first element of service connection, there is more than ample evidence that the Veteran currently has renal cell carcinoma. (See April 2012 report, prepared by J. T., M. D., MPH, reflecting that the Veteran was diagnosed with renal cancer in 2001). With respect to crucial Hickson element (2), in-service disease or injury, the Veteran's DD 214 reflects that he served in the RVN from January 23, 1970 to December 14, 1970. Thus, his exposure to herbicides in the RVN is presumed. 38 U.S.C.A. § 1116 (f). As to the Veteran's exposure to benzene chemicals, his DD 214 reflects that his military occupational specialist was a surveillance infrared repairman, 26 N 20, a position, according to the website, www.ichiban.org/html/history_mos.htum, required him to work around airplanes; thus, exposing him to jet fuel, which most likely contained a small concentration of benzene chemicals. Thus, the Board finds the Veteran's contention that he was exposed to benzene chemicals during military service consistent with the circumstances therein. 38 U.S.C.A. § 1154(a)(West 2002). Thus, the Board finds Hickson element (2), evidence of an in-service event has been met. With respect to Hickson element (3), nexus or relationship, there are private and VA examiners' opinions that are supportive of and against the claim for service connection for a right kidney disorder, to include renal cell carcinoma. As noted by the Board in its January 2012 remand, in a June 2009 report, a urologist, M.W., M.D., noted the Veteran's history of being exposed to Agent Orange and other chemicals in his line of work while in the military. M. W. M, D., opined that there was some data to suggest that this exposure "may have increased the likelihood of [the Veteran] developing renal carcinoma" and added that there is "at least a 50 percent probability that this may be an etiological factor in this tumor." In January 2012, the Board found M. W., M. D.'s June 2009 opinion too speculative because of the use of the word "may", to be the basis for an award of service connection. See Obert v. Brown, 5 Vet. App. 30, 33 (1993) (finding that a medical opinion that stated "may" also implied "may not" and was therefore speculative); Morris v. West, 13 Vet. App. 94, 97 (1999) (diagnosis that appellant was "possibly" suffering from schizophrenia deemed speculative). Additionally, and as noted by the Board in January 2012, Dr. M. W. did not provide any supporting rationale for his June 2009 opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). M. W., M. D., submitted a more definitive opinion in February 2012. In that report, Dr. M. W. opined, " I feel that there is a definite causative relationship of benzene exposure causing renal cell carcinoma." Dr. M. W. further noted that medical published data clearly demonstrated, in both humans and animals, that benzene had a greater than 50 percent chance of causing renal cell carcinoma. Dr. M. W. did not cite to any specific medical literature or publications in support of his opinion, but only offered a general conclusory statement. Thus, the Board finds Dr. M. W.'s February 2012 to be of minimal probative value. Id. In August 2009 and February 2012, the same VA examiner examined the Veteran and provided an opinion as to the etiology of the Veteran's renal cell carcinoma. After a review of the claims files and physical evaluation of the Veteran, the VA examiner stated that she could not provide an opinion as to whether the Veteran's renal cell cancer had been caused by his in-service exposure to Agent Orange exposure and benzene chemicals without resort to speculation. At the close of the February 2012 examination, the VA examiner reasoned that available medical literature did not support an established cause and effect relationship between the Veteran's presumed exposure to Agent Orange or benzene chemicals and clear cell kidney cancer. The VA examiner noted that there were Veterans who had received service connection for kidney cancer as due to Agent Orange and that the medical literature rationale for these awards was unclear. (See August 2009 genitourinary and February 2012 kidney conditions (nephrology) examination reports)). The Board finds the VA examiner's February 2012 opinion to be of minimal probative value because it is in direct conflict with a news article that was presented at a conference of the American Urological Association noting an apparent link between Agent Orange and kidney cancer in Veterans that were exposed to herbicides in Vietnam in a new study. Thus, as the VA examiner's opinion is based on an inaccurate premise, namely that medical literature did not support an established cause and effect relationship between the Veteran's presumed exposure to Agent Orange or benzene chemicals and clear cell kidney cancer, it is afforded minimal probative value. See Kahana v. Shinseki, 24 Vet. App. 428, 439 (2011) (noting that a medical opinion based upon an incorrect factual premise is of no probative value). In contrast to the VA examiner's opinions is an April 2012 report, prepared by J. T., M.D., MPH, a medical toxicologist and specialist in occupational/environmental medicine, that is favorable to the claim. After an extensive recitation of the Veteran's service and post-service medical history, a review of a number of medical studies that demonstrated an association between renal carcinoma and Agent Orange and benzene chemicals, and an absence of any cause for the Veteran's renal cell cancer, to include a lack of occupational exposure during his employment as a union representative for a railroad company and tobacco use that ended in 1982, 20 years before he was diagnosed with renal cell cancer in 2001, Dr. J. T. opined, " In my medical opinion, with greater than 50 percent certainty, the Veteran's renal cell cancer was likely caused by his exposure to benzene and Agent Orange in Vietnam." (See April 2012 report, prepared by J. T., M. D., MPH). The Board finds Dr. J. T.'s opinion to be of high probative value because it is supported by several medical studies and medical rationale that is specific to the Veteran's personal medical history. Nieves, supra. Overall, the Board finds that there is an approximate balance of positive and negative medical evidence on the issue of whether the Veteran's renal cell carcinoma was caused by the Veteran's presumed in-service exposure to Agent Orange and benzene chemicals. Whenever there is an approximate balance of positive and negative evidence on any issue material to the determination of the matter, the benefit of the doubt will be resolved in the Veteran's favor. Accordingly, resolving the benefit of the doubt in this case in the Veteran's favor, the Board will grant service connection for renal cell carcinoma secondary to in-service exposure to Agent Orange and benzene chemicals. 38 U.S.C.A. § 5107(b). ORDER Service connection for gastrointestinal disorder, claimed as ulcerative proctitis, as secondary medications prescribed for service-connected CAD, is granted. Service connection for renal cell carcinoma as secondary to exposure to Agent Orange and benzene chemicals, is granted. REMAND As noted in the Introduction, the Board finds that additional substantive development is warranted to address the claims for service connection for hemorrhoids, to include as secondary to medications prescribed for CAD and service-connected ulcerative proctitis and entitlement to service connection for hemorrhoids, to include as due to in-service exposure to Agent Orange and benzene chemicals. (i) Hemorrhoids The Veteran contends that he has hemorrhoids that are secondary to medications prescribed for his service-connected CAD and service-connected ulcerative proctitis. With respect to his contention that his hemorrhoids are secondary to medications prescribed for his CAD, no examiner, private or VA, has addressed this argument. Although the same VA physician examined the Veteran in August 2009 and February 2012 and provided an opinion as to the direct and secondary service connection components of the claim, no clinician, private or VA, has addressed the Veteran's argument that medications prescribed for the service-connected CAD had caused or aggravated the Veteran's hemorrhoids. In addition, as the Board's decision herein grants service connection for a gastrointestinal disability, to include ulcerative proctitis, it finds that there is insufficient medical evidence upon which to decide the claim for hemorrhoids as secondary thereto. Thus, in view of the foregoing the Board finds that remand is required to obtain a medical opinion as to whether the Veteran's ulcerative proctitis has been caused or aggravated (beyond its normal progression) by medications prescribed for the service-connected CAD and/or service-connected ulcerative proctitis. (ii) Hypertension The Veteran seeks service connection for hypertension, to include as secondary to his service-connected CAD and in-service exposure to Agent Orange and benzene chemicals. In January 2012, the Board remanded the claim for service connection for hypertension to have the RO schedule the Veteran for an examination with an opinion that addressed the relationship, if any, between the Veteran's service-connected CAD and hypertension. This examination was performed in February 2012 by the same VA examiner who had previously examined the Veteran in August 2009. (See August 2009 and February 2012 VA hypertension examination report). After a physical evaluation of the Veteran and a review of the claims files in February 2012, the VA examiner opined, in pertinent part, that the Veteran's hypertension had not been caused or aggravated by the service-connected CAD. The VA examiner reasoned that the Veteran hypertension had its onset in 1982, and his CAD in 2007. In addition, she noted that medical literature did not support the claim that CAD caused hypertension. Id. The Board finds the VA examiner's February 2012 opinion to be in direct conflict with her clinical finding in August 2009 that the Veteran had "hypertension complicated by CAD." (See August 2009 VA hypertension examination report, page 2). Thus, given the inherent internal inconsistencies between the VA examiner's findings in August 2009 and February 2012 as to the etiological relationship between the Veteran's service-connected CAD and hypertension, the Board finds that a new addendum opinion should be obtained to resolve these internal inconsistencies. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (a thorough examination "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"); see also Barr v. Nicholson, 21 Vet. App. 303 (2007) (when VA undertakes the effort to provide an examination, it must provide an adequate one). Accordingly, the case is REMANDED for the following action: 1. Send the claims file to an appropriate VA examiner to provide an opinion as to the etiological relationship between his hemorrhoids and medications prescribed for his service-connected CAD and service-connected ulcerative proctitis. The claims files shall be made available to and reviewed by the examiner. The Veteran need not be re-examined unless an examination is deemed necessary. In the event that such an examination is warranted, all necessary clinical testing should be performed. The reviewing shall provide opinions to the following questions: (i) Is it as least as likely as not that the Veteran's hemorrhoids are due to or have been aggravated (permanently worsened beyond natural progression) by medications prescribed for the service-connected CAD? (ii) Is it as least as likely as not that the Veteran's hemorrhoids are due to or have been aggravated (permanently worsened beyond natural progression) by the service-connected gastrointestinal disorder, to include ulcerative proctitis? If aggravation is found, the reviewer shall opine, if possible, as to (a) the baseline level of hemorrhoids prior to the aggravation and (b) the current level of hemorrhoids. A complete explanation (rationale) shall be provided for each opinion. If any opinion cannot be provided without resort to mere speculation, the reviewer shall provide a complete explanation for why this is so. In so doing, the reviewer specifically shall indicate whether or not the inability to render the opinion is the result of a need for additional information or of the limits of current medical knowledge having been exhausted. 2. Send the claims file, if possible, to the examiner who prepared the August 2009 and February 2012 VA hypertension examination reports for the purpose of preparing an addendum opinion regarding the etiological relationship between the Veteran's service-connected CAD and hypertension. The claims files should be made available and reviewed by the examiner. If the August 2009/February 2012 VA hypertension examiner is not available, please forward this matter to a qualified examiner for review of the claims files and preparation of the aforementioned opinion. The Veteran need not be re-examined unless an examination is deemed necessary. In the event that such an examination is warranted, all necessary clinical testing should be performed. In the requested addendum opinion, the examiner should, first and foremost, clarify the inconsistencies between her August 2009 statement that "hypertension complicated by CAD" with her February 2012 opinion, which indicates that the Veteran's hypertension had not been caused or aggravated by his service-connected CAD. The VA examiner must then determine whether a review of the inherent inconsistencies in the August 2009 and February 2012 examination reports change her February 2012 opinion that the Veteran's hypertension had not been caused or aggravated by the service-connected CAD. Specifically, the examiner shall render an opinion as to the following question: Is it as least as likely as not that the Veteran's hypertension has been aggravated (permanently worsened beyond natural progression) by the service-connected CAD? A complete explanation (rationale) shall be provided for each opinion. If any opinion cannot be provided without resort to mere speculation, the reviewer shall provide a complete explanation for why this is so. In so doing, the examiner or reviewer specifically shall indicate whether or not the inability to render the opinion is the result of a need for additional information or of the limits of current medical knowledge having been exhausted. 3. To help avoid future remand, the RO must ensure that all requested action has been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 4. After completing the requested action, and any additional notification and/or development deemed warranted, the RO should readjudicate the claims for service connection for hemorrhoids, to include as secondary to medications prescribed for the service-connected CAD and service-connected ulcerative proctitis and entitlement to service connection for hypertension, to include as secondary to CAD and exposure to Agent Orange and benzene chemicals in light of all pertinent evidence and legal authority. 5. If any benefit sought on appeal remains denied, the RO must furnish the Veteran and his representative an appropriate Supplemental Statement of the Case that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims folders are returned to the Board for further appellate consideration. 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). These claims 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). ______________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs