Citation Nr: 1331292 Decision Date: 09/27/13 Archive Date: 10/01/13 DOCKET NO. 06-28 185A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for a left shoulder disability. 4. Entitlement to service connection for a gastrointestinal disability, to include gastroesophageal reflux disease (GERD), and to include as secondary to a service-connected thoracolumbar spine disability and posttraumatic stress disorder (PTSD). 5. Entitlement to service connection for a cardiac disorder, to include as secondary to a service-connected PTSD disability and under the provisions of 38 U.S.C.A. § 1151. 6. Entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for the residuals of bladder cancer. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. J. Houbeck, Counsel INTRODUCTION The Veteran had active service in the United States Air Force from June 1962 to June 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of October 2007 and January 2009 of the New Orleans, Louisiana, Regional Office (RO), of the Department of Veterans Affairs (VA), which denied the benefits sought on appeal. In February 2011, the Veteran provided testimony before the undersigned Veterans Law Judge (VLJ) via a videoconference hearing. A transcript of that hearing was produced and has been included in the claims file. The above claims were remanded for further development by the Board in June 2011. The matter again is before the Board. The Board notes that the June 2011 Board remand also included the issue of entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD). In a March 2013 rating decision, the Appeals Management Center (AMC) granted entitlement to service connection for PTSD and depressed mood was considered in assigning the rating. This decision was a complete grant of benefits with respect to this issue. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). The issues of entitlement to service connection for a left shoulder disability, a gastrointestinal disability, and a cardiac disorder, as well as entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for the residuals of bladder cancer 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 preponderance of the evidence is against finding that the Veteran has a bilateral hearing loss disability that is etiologically related to a disease, injury, or event in service. 2. The preponderance of the evidence is against finding that the Veteran has a tinnitus disability that is etiologically related to a disease, injury, or event in service. CONCLUSIONS OF LAW 1. A bilateral hearing loss disability was not incurred in and is not otherwise related to service, nor may it be presumed to have occurred therein. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.385 (2013). 2. A tinnitus disability was not incurred in and is not otherwise related to service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims, VA has met all statutory and regulatory notice and duty to assist provisions. 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(a) (2013). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the Veteran and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the Veteran is expected to provide; and (4) request that the Veteran provide any evidence in his or her possession that pertains to the claim. The requirement of requesting that the Veteran provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. VCAA letters dated in January 2007 and July 2011 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b)(1) (2009); Quartuccio, at 187. The Veteran was advised that it was ultimately his responsibility to give VA any evidence pertaining to the claims. The letters informed him that additional information or evidence was needed to support his claims, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. The letters also explained to the Veteran how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). As noted above, the Veteran also was afforded a hearing before the undersigned Veterans Law Judge (VLJ) during which he presented oral argument in support of his claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the VLJ/DRO who chairs a hearing fulfill two duties to comply with the above the regulation. These duties 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. Here, the VLJ fully explained the issues on appeal during the hearing and specifically discussed the basis of the prior determination, the element(s) of the claims that were lacking to substantiate the claims for benefits, and suggested the submission of evidence that would be beneficial to the Veteran's claims. Indeed, in part based on the information elicited from the Veteran during the February 2011 Board hearing, the Board remanded the Veteran's claims for additional development in June 2011. Significantly, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claims. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA treatment records are in the file. As will be discussed in greater detail below, remand for several additional records is necessary for the Veteran's other claims. While these records have not been associated with the claims file to this point, as there is no indication that these records implicate the hearing loss or tinnitus claims, the Veteran is not prejudiced by the Board proceeding to a decision as to these claims. Records from the Social Security Administration (SSA) also have been associated with the claims file. Private treatment records identified by the Veteran were obtained, to the extent possible. In that regard, the Board notes that the Veteran has contended that numerous private treatment records with multiple private treatment providers were destroyed as the result of Hurricane Katrina. The Veteran has at no time otherwise referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4)(i) (2013). The Veteran was provided a VA examination for his bilateral hearing loss and tinnitus in October 2012. The examiner diagnosed bilateral sensorineural hearing loss and tinnitus. The VA examiner concluded, however, that the Veteran's hearing loss and tinnitus was unrelated to his military service, as the Veteran had normal hearing at entrance and separation, no threshold shift during service, and worked in construction from 1988 to 2000 that included the use of power tools. As will be discussed in greater detail below, the examiner took into account the Veteran's reported history, his current symptoms, review of the available private and VA treatment records, and the results of physical and diagnostic examinations. Therefore, the Board finds the examination report to be thorough and complete and sufficient upon which to base a decision with regards to these claims. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Based on the association of VA treatment records, SSA records, July 2011 notice letter, the October 2012 VA examination report, and the subsequent readjudication of the claims, the Board finds that there has been substantial compliance with its June 2011 remand directives with respect to his hearing loss and tinnitus claims. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Service Connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110, 1131 (West 2002). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (2013). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). For veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including hearing loss, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2013). In the instant case, there is no presumed service connection because the Veteran was not diagnosed with a hearing loss disability within one year of service and, indeed, was not diagnosed until decades after service. In the absence of presumptive service connection, to establish a right to compensation for a present disability on a direct basis, a Veteran must show: "(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." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). With respect to claims for service connection for hearing loss, the United States Court of Appeals for Veterans Claims (Court) has held that the threshold for normal hearing is from 0 to 20 decibels, and that higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The Court further opined that 38 C.F.R. § 3.385, discussed below, then operates to establish when a hearing loss disability can be service connected. Id at 159. 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, 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. Here, the Veteran alleges that he has current bilateral hearing loss and tinnitus due to in-service noise exposure. Specifically, the Veteran asserts that he had significant noise exposure from airplane engines and machinery while working on or near the flight line as a mechanic. The Veteran's personnel records confirm service as a jet aircraft mechanic. While the Veteran concedes that he was provided hearing protection for his work, the Board recognizes that exposure to significant acoustic trauma is possible. For the purpose of this decision alone, therefore, in-service acoustic trauma may be presumed. The Veteran's service treatment records, however, are silent as to any complaints, treatment or diagnoses of hearing loss or tinnitus. At the Veteran's April 1966 separation examination, he denied a history of ear trouble or hearing loss. Similarly, audiometric testing was within normal limits bilaterally, as it had been on entrance into service. After service, during the Veteran's February 2011 Board hearing he acknowledged that he did not notice chronic decreased hearing acuity or tinnitus until after separation from service, instead noting onset "probably" in 1967 and progressing from that point. During service, the Veteran reported intermittent ringing in the ears and/or decreased hearing acuity, but that after exposure to acoustic trauma from jet engines and other noises from the flight line, "You hear it for a while afterwards and then you kind of, either you get used to it or it subsides, whichever it is uh, it just doesn't affect you as much." In support of his claim, the Veteran submitted an undated private audiogram showing a bilateral hearing loss disability as defined by 38 C.F.R. § 3.385 (2013). As noted, the Veteran was afforded a VA audio examination in October 2012. The examiner noted review of the claims file. The Veteran reported noticing a ringing or "cricket" sound in his left ear from around 2005. He was able to drown out the ringing, but it was aggravating, particularly at night when trying to sleep. The Veteran also had difficulty hearing and understanding certain people, particularly in group situations. The examiner concluded that it was not at least as likely as not that the Veteran's hearing loss and tinnitus disabilities were caused by or the result of his military service. The rationale was that the Veteran had normal hearing at induction and separation (with no evidence of a threshold shift in hearing acuity during service) and that he had worked in construction from 1988 to 2000, which involved being in proximity to power tools being used. Thus, the Veteran has current bilateral sensorineural hearing loss and tinnitus disabilities. The pertinent inquiry, then, is whether the Veteran's current bilateral hearing loss and tinnitus were caused by any incident of service, to include noise exposure from jet aircraft and working on the flight line. The Board concludes they were not. The Board finds the opinions as to the etiology of the Veteran's hearing loss and tinnitus expressed in the October 2012 VA examiner's examination report of significant probative value. The examination was based on a review of the claims file, interview of the Veteran, and audio examination. The VA examiner considered the Veteran's reported in-service noise exposure from aircraft engines and other noise while working on or near the flight line, but concluded that it was less likely than not that his current hearing loss and tinnitus were related to his military service. The examiner discussed the absence of a hearing loss disability at entrance and separation from service, the absence of a threshold shift in hearing acuity during service, and the Veteran's work in the construction industry for over a decade after service that involved being around power tools. While the Board acknowledges that the examiner indicated some other cause than "explosions" experienced during service were the cause of the Veteran's tinnitus, in context the examiner clearly examined the evidence of record and understood that the Veteran's claim was based not on exposure to explosions, but aircraft engines and other noises associated with his work as a jet aircraft mechanic. This conclusion is evidenced by the examiner's discussion and outline of the evidence of record, including the notation of specific dates of examinations and audiograms. Thus, the examiner clearly considered the merits of the Veteran's specific claim and any reference to "explosions" was a typographical or other error. See Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (observing that medical reports must be "read as a whole" in the determination of adequacy); see also Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (noting that an adequate medical report need not "explicitly lay out the examiner's journey from the facts to a conclusion," as long as the rationale is clear from a reading of the report as a whole). Consequently, the Board finds this report to be the most probative evidence of record as to whether his current hearing loss disability and tinnitus are related to service. The Board has considered the Veteran's contentions that his current bilateral hearing loss and tinnitus were caused by his in-service exposure to noise from jet aircraft and other sources during his work as an aircraft mechanic. In this regard, the Veteran is certainly competent to report that he experiences difficulty hearing and tinnitus is the type of disability that is capable of lay diagnosis. See Charles v. Principi, 16 Vet. App. 370, 374- 75 (2002). In this case, the Veteran concedes that he did not have continuous hearing difficulty or tinnitus from service. As discussed above, the Veteran reported during his February 2011 Board hearing that he first noted problems the year after separating from service, while during the October 2012 VA examination he indicated that tinnitus began in about 2005. The Board also finds it highly significant that the Veteran denied a history of hearing loss or ear problems at the time of his separation examination. Moreover, the Veteran as a lay person has not been shown to be capable of making medical conclusions, especially as to complex medical diagnoses such as a link between any current hearing loss and tinnitus and in-service noise exposure where any decreased hearing acuity and tinnitus did not manifest until some time, even multiple decades, after service. Given the Veteran's lack of demonstrated medical expertise, the Board finds that the opinion of the competent medical professional to be the most probative evidence of record as to the relationship between the Veteran's current bilateral hearing loss and tinnitus and his military service, and the Board is of the opinion that this opinion ultimately outweighs the Veteran's contentions as to etiology absent continuous symptomatology of decreased hearing acuity or tinnitus. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions); see also Layno v. Brown, 6 Vet. App. 465 (1994) (cautioning that lay testimony that the Veteran suffered a particular illness (bronchial asthma) was not competent evidence because matter required medical expertise). In summary, no medical professional has linked the Veteran's current bilateral hearing loss and tinnitus to service, and, in fact, there is medical evidence to the contrary. Moreover, the Veteran reports that he did not notice any chronic decreased hearing acuity or tinnitus until after service. In addition, there were no complaints or findings of tinnitus and hearing loss upon separation examination. In light of the evidence, the Board concludes that the preponderance of the evidence is against the claims, and that service connection for bilateral hearing loss and tinnitus is not warranted. As the preponderance of the evidence is against the claims, the benefit-of-the-doubt rule does not apply, and the claims must be denied. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. REMAND In addition, the Veteran seeks entitlement to compensation benefits for a gastrointestinal disability, a left shoulder disability, a cardiac disorder, and residuals of bladder cancer, either through direct or secondary service connection or through the provisions of 38 U.S.C.A. § 1151. Despite the extensive procedural development already undertaken, the Board concludes that another remand is required. As to the Veteran's gastrointestinal disability and cardiac disorder claims, in a June 2013 statement the Veteran's representative argued for the first time that these disabilities could have been caused or aggravated by the Veteran's service-connected PTSD. The statement cited multiple medical sources suggesting the possibility of such a link. As such, the Board concludes that an addendum opinion to the September 2012 gastrointestinal and December 2012 heart (with January 2013 addendum), is required prior to adjudication of the claims. The addenda also should include opinions as to establishing entitlement to service connection for heart problems on a direct basis and for the gastrointestinal problems as secondary to the Veteran's service-connected back disability. Moreover, the June 2011 Board remand requested that hospitalization and treatment records be obtained for the Veteran's claimed hospitalization for gastroduodenitis. In that regard, there is a record showing treatment from May 14, 1965 to May 16, 1965, that included a diagnosis of gastroduodenitis. There is no indication if this is the sole record of such treatment. The AMC requested a copy of the Veteran's 1965 clinical records from Forbes Air Base in Topeka, Kansas, but the records received did not include any additional documents relating to that period of hospitalization. It appears from the records documenting the hospitalization already of record that the Veteran may have been on temporary duty (TDY) at the time, as the records indicate that the treatment facility was TUSLOG Detachment 47 and/or Detachment 50. As such, efforts should be made to obtain the hospitalization records from all appropriate sources. In addition, the June 2011 Board remand directed the AMC/RO to "print-out a copy of the scanned May 29, 2008, VA cardiology report (see June 12, 2008, outsourced consultation report) and the scanned February 21, 2007, VA cardiology consult (see February 22, 2007, Consult Coordination Center note)." In an attempt to comply with the Board's instructions, the AMC requested these records from the VAMC in September 2011. The resulting September 2011 response from the VAMC, however, included the same treatment records referencing the May 29, 2008 report and February 22, 2007 note, without actually including the records. As such, another request must be made for these records. The Board also observes that the Veteran has referenced treatment for his claimed disabilities at various private treatment facilities, including the Tulane University Medical Center, River Parish Hospital, St. Charles Parish Hospital, and Ochsner Medical Center in Kenner, Louisiana. A letter to the Veteran should be sent requesting that authorization to obtain these records be provided to VA or, in the alternative, that such records could be provided by the Veteran directly to VA. The AMC also should provide the Veteran a letter requesting that he provide any vouchers, orders, or other evidence relating to his alleged temporary duty (TDY) for approximately 26 days that included flights to Vietnam. As to the residuals of bladder cancer claim, the sole rationale expressed in the November 2012 VA examination report concluding that the Veteran's evaluation and treatment for urinary issues that failed to diagnose bladder cancer was not due to carelessness, negligence, lack of proper skill, or an error in judgment was "due to the short time frame involved." It is unclear from this statement whether the examiner intended to indicate that the Veteran did not incur an additional disability due to the relatively short passage of time or something else entirely. Given this confusion, the Board concludes that an addendum opinion to the November 2012 is required. Moreover, the Veteran has indicated private treatment for his bladder problems from a Dr. Boyd. A letter to the Veteran should be sent requesting that authorization to obtain these records be provided to VA or, in the alternative, that such records could be provided by the Veteran directly to VA. As to the Veteran's left shoulder claim, the Veteran contends that he initially injured his left shoulder during a motor vehicle accident in June 1963. Service treatment records indicate that the Veteran was hospitalized at Caney Municipal Hospital in Caney, Kansas from June 10, 1963 to June 11, 1963. A letter to the Veteran should be sent requesting that authorization to obtain these records be provided to VA or, in the alternative, that such records could be provided by the Veteran directly to VA. Accordingly, the case is REMANDED for the following action: 1. Ensure that all VCAA notice obligations are satisfied in accordance with 38 U.S.C.A. §§ 5102, 5103, and 5103A, implementing regulations, interpretative precedent Court decisions, and any other applicable legal precedent. In particular, the veteran should be informed of how to establish his claim of secondary service connection under 38 C.F.R. § 3.310, with respect to the Veteran's cardiac and gastrointestinal claims. 2. Ask the Veteran to provide any vouchers, orders, or other documentation of his claimed temporary duty (TDY) to Vietnam for approximately 26 days. 3. Ask the Veteran to identify and provide release forms authorizing VA to request his treatment records from any private doctor for treatment for the claimed disabilities on appeal, to include Dr. Boyd, St. Charles Parish Hospital, Tulane University Medical Center, River Parish Hospital, and Ochsner Medical Center in Kenner, Louisiana; as well as from Caney Municipal Hospital in Caney, Kansas for his hospitalization from June 10, 1963 to June 11, 1963. These medical records should then be requested, and the RO should specify that actual treatment records, as opposed to summaries, are needed. All efforts to obtain these records, including follow-up requests, if appropriate, should be fully documented. 4. The RO/AMC should obtain VA documents as follows: a. The contents of the scanned May 29, 2008 VA cardiology report (see June 12, 2008, outsourced consultation report noting); and b. the contents of the scanned February 21, 2007 VA cardiology consult (see February 22, 2007, Consult Coordination Center note). Please note that the Board does not have access to the scanned contents and merely reprinting the June 12, 2008 and February 21, 2007 treatment records referencing the above records is insufficient. If the AMC is also unable to retrieve the content of the documents that were scanned into CAPRI, a request should be made directly to the VA Medical Center for copies of the contents of the scanned records. 5. Request from all appropriate sources hospitalization and treatment records for gastroduodenitis from May 14, 1965 to May 16, 1965, that was provided by the treatment facility TUSLOG Detachment 47 and/or Detachment 50. If such records cannot be obtained, the efforts undertaken to obtain these records must be set forth in writing and associated with the claims file. All attempts to fulfill this development should be documented in the claims file. If after continued efforts to obtain the records it is concluded that it is reasonably certain they do not exist or further efforts to obtain them would be futile, the AMC must notify the Veteran and (a) identify the specific records the AMC is unable to obtain; (b) briefly explain the efforts that the AMC made to obtain those records; (c) describe any further action to be taken by the AMC with respect to the claim; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 6. After the above evidence is obtained, to the extent available, obtain a supplemental opinion from the examiner who conducted the December 2012 VA heart examination and provided the January 2013 addendum opinion. If the examiner is not available, obtain an opinion from another appropriate medical professional. If the reviewer determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. However, the Veteran should not be required to report for another examination as a matter of course, if it is not found to be necessary. The claims file must be made available to and reviewed by the reviewer/examiner. The reviewer/examiner is asked to provide opinions with respect to the following questions: a. Whether it is as least as likely as not (50 percent probability or more) that any current cardiac disorder was incurred in or is otherwise related to the Veteran's military service; b. whether it is as least as likely as not (50 percent probability or more) that any current cardiac disorder was caused by the Veteran's service-connected PTSD; and c. whether it is as least as likely as not (50 percent probability or more) that any current cardiac disorder was aggravated (i.e., worsened) beyond its natural progression by the Veteran's service-connected PTSD. The examiner/reviewer's attention is directed to the Veteran's complaints with respect to chest pain in service and the medical references discussed in the June 2013 statement of the Veteran's representative. The examiner/reviewer should provide a complete rationale for any opinion provided. If the examiner/reviewer determines that an opinion cannot be made without resort to mere speculation, then it should be clear in the remarks whether it cannot be determined from current medical knowledge that a specific in-service injury or disease or service-connected disability could possibly cause the claimed disorders, or whether the actual cause is due to multiple potential causes. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 7. Obtain a supplemental opinion from the examiner who conducted the September 2012 VA gastrointestinal examination. If the examiner is not available, obtain an opinion from another appropriate medical professional. If the reviewer determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. However, the Veteran should not be required to report for another examination as a matter of course, if it is not found to be necessary. The claims file must be made available to and reviewed by the reviewer/examiner. The reviewer/examiner is asked to provide opinions as follows: a. whether it is as least as likely as not (50 percent probability or more) that any current gastrointestinal disorder was caused by the Veteran's service-connected PTSD; b. whether it is as least as likely as not (50 percent probability or more) that any current gastrointestinal disorder was aggravated (i.e., worsened) beyond its natural progression by the Veteran's service-connected PTSD; c. whether it is as least as likely as not (50 percent probability or more) that any current gastrointestinal disorder was caused by the Veteran's service-connected thoracolumbar spine disability, in particular, the medications taken therefore; and d. whether it is as least as likely as not (50 percent probability or more) that any current gastrointestinal disorder was aggravated (i.e., worsened) beyond its natural progression by the Veteran's service-connected thoracolumbar spine disability, in particular, the medications taken therefore. e. If aggravation is found, the examiner should address the following medical issues: (1) the baseline manifestations of the Veteran's heart and/or gastrointestinal disability found prior to aggravation; and (2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected PTSD and/or thoracolumbar spine disability. The examiner/reviewer's attention is directed to the medical references discussed in the June 2013 statement of the Veteran's representative. The examiner/reviewer should provide a complete rationale for any opinion provided. If the examiner/reviewer determines that an opinion cannot be made without resort to mere speculation, then it should be clear in the remarks whether it cannot be determined from current medical knowledge that a specific in-service injury or disease or service-connected disability could possibly cause the claimed disorders, or whether the actual cause is due to multiple potential causes. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 8. Obtain a supplemental opinion from the examiner who conducted the November 2012 VA genitourinary examination. If the examiner is not available, obtain an opinion from another appropriate medical professional. If the reviewer determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. However, the Veteran should not be required to report for another examination as a matter of course, if it is not found to be necessary. The examiner/reviewer should be advised that the rationale "I do not think the evaluation and treatment by VA was careless, negligent, lacking proper skill, or an error of judgment or similar fault due to the short time frame involved" is unclear. The examiner/reviewer is asked to address with an explanation as to the basis for the conclusion the following: a. Was the treatment the Veteran received at VA immediately prior to the discovery of bladder cancer proper? b. Did VA fail to exercise the degree of care that would be expected of a reasonable health care provider? c. Was the treatment and the care provided by VA personnel: (1) Careless; (2) Negligent; (3) Indicative of medical personnel lacking proper skill; (4) An error in judgment; or (5) A similar instance of fault? d. Was there a lack of care or failure to diagnose the bladder cancer that resulted in an additional disability? A complete rationale for all opinions expressed must be provided. The claims file must be made available to the examiner for review prior to the examination. 9. After the above is complete, readjudicate the Veteran's claims. If a complete grant of the benefits requested is not granted, issue a supplemental statement of the case (SSOC) to the Veteran and his representative, and they should be given an opportunity to respond, before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ S. S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs