Citation Nr: 1332942 Decision Date: 10/22/13 Archive Date: 10/24/13 DOCKET NO. 11-19 682 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for diabetes mellitus, type II to include as due to herbicide exposure. 3. Entitlement to service connection for coronary artery disease to include as due to herbicide exposure. 4. Entitlement to service connection for hypertension to include as secondary to diabetes mellitus, type II. 5. Entitlement to service connection for hypercholesterolemia to include as secondary to diabetes mellitus, type II. 6. Entitlement to service connection for a vision disorder to include as secondary to diabetes mellitus, type II. WITNESSES AT HEARING ON APPEAL Appellant and his brother (F.D.G.) ATTORNEY FOR THE BOARD April Maddox, Counsel INTRODUCTION The Veteran had active service from February 1955 to May 1958 and again from May 1963 to September 1974. This matter comes before the Board of Veterans' Appeals (Board) from February and May 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The Veteran and his brother, F.D.G., testified before the undersigned Veterans Law Judge at a Board Videoconference hearing in August 2013. A transcript of this proceeding has been associated with the claims file. During the hearing the Veteran indicated that he would submit additional evidence in support of his claim and that he waived RO consideration of all additional evidence submitted. Such evidence was submitted subsequently in August 2013. Accordingly, the Board may properly consider this evidence in the first instance. 38 C.F.R. § 20.1304(c). The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the Virtual VA claims file does not reveal any additional documents pertinent to the present appeal with the exception of a transcript of the August 2013 Board Videoconference hearing. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issues of entitlement to service connection for hypertension, hypercholesterolemia, and a vision disorder 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. Resolving all doubt in favor of the Veteran, bilateral hearing loss is etiologically related to noise exposure during the Veteran's active duty service. 2. The Veteran's military occupational specialty was as a flight attendant. 3. The Veteran's statements that he visited Vietnam for approximately 30 days in 1969 are consistent with his military records and generally-available historical information about his location and unit off the coast of Vietnam, and herbicide exposure in his case may be conceded. 4. The medical evidence establishes that a diagnosis of diabetes mellitus has been made. 5. The medical evidence establishes that a diagnosis of coronary artery disease has been made. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss have been met. 38 U.S.C.A. §§ 1110, 1131, 1112, 1116, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). 2. The criteria for service connection for diabetes mellitus, type II, as presumed related to active military service, are met. 38 U.S.C.A. §§ 1110, 1131, 1112, 1113, 1116, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.1, 3.6, 3.102, 3.303, 3.307, 3.309 (2013). 3. The criteria for service connection for coronary artery disease, as presumed related to active military service, are met. 38 U.S.C.A. §§ 1110, 1131, 1112, 1113, 1116, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.1, 3.6, 3.102, 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran contends that his bilateral hearing loss, diabetes mellitus, type II, and coronary artery disease are related to his service with the United States Navy from February 1955 to May 1958 and again from May 1963 to September 1974. With regard to the claim for bilateral hearing loss, the Veteran contends that he that he worked on the flight deck of an aircraft carrier in close proximity to noisy aircraft and did not use hearing protection. The Veteran attributes his current bilateral hearing loss to this acoustic trauma. With regard to the claims for diabetes mellitus, type II, and coronary artery disease, the Veteran notes that diabetes mellitus and coronary artery disease (which is synonymous with ischemic heart disease) are presumptive disorders for those Veteran's who set foot in Vietnam during the Vietnam era pursuant to 38 C.F.R. § 3.309 and he contends that, despite a June 2008 finding that there was no conclusive proof of in-country Vietnam service, the Veteran was in DaNang, Vietnam for a period of approximately 30 days in 1969 visiting his brother who was stationed there. Analysis 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, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as organic diseases of the nervous system, 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; 38 C.F.R. §§ 3.307, 3.309. In an October 4, 1995, opinion, VA's Under Secretary for Health determined that it was appropriate to consider high frequency sensorineural hearing loss an organic disease of the nervous system and therefore a presumptive disability. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). The use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a), such as organic diseases of the nervous system, and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Bilateral hearing loss Service connection for impaired hearing is subject to 38 C.F.R. § 3.385, which provides that 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. The Board acknowledges that the lack of any evidence that the Veteran exhibited hearing loss during service is not fatal to his claim. The laws and regulations do not require in service complaints of or treatment for hearing loss in order to establish service connection. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Instead, as noted by the United States Court of Appeals for Veterans Claims (Court): [W]here the regulatory threshold requirements for hearing disability are not met until several years after separation from service, the record must include evidence of exposure to disease or injury in service that would adversely affect the auditory system and post- service test results meeting the criteria of 38 C.F.R. § 3.385 ....For example, if the record shows (a) acoustic trauma due to significant noise exposure in service and audiometric test results reflecting an upward shift in tested thresholds in service, though still not meeting the requirements for "disability" under 38 C.F.R. § 3.385, and (b) post-service audiometric testing produces findings meeting the requirements of 38 C.F.R. § 3.385, rating authorities must consider whether there is a medically sound basis to attribute the post-service findings to the injury in service, or whether they are more properly attributable to intercurrent causes. Hensley v. Brown, 5 Vet. App. 155, 159 (1993) (quoting from a brief of the VA Secretary). The Veteran had two separate periods of service. The Veteran's enlistment examination from his first period of service in February 1955 shows that the Veteran's ears were clinically evaluated as normal. No hearing abnormality was noted by the examiner and there was no indication of any complaints of hearing loss by the Veteran. Based on appropriate hearing testing at the time, the Veteran's hearing was 15/15 with whispered voice test. A May 1958 separation examination again showed that the Veteran's hearing was 15/15 with whispered voice test. The ears were also clinically evaluated as normal. Prior to November 1967, audiometric test results were reported in standards set forth by the American Standards Association (ASA). Since November 1, 1967, those standards have been set by the International Standards Organization (ISO)-American National Standards Institute (ANSI). The converted numbers are in parentheses. Service treatment records from the Veteran's second period of service also show normal hearing. Specifically, in an April 1963 enlistment examination the Veteran's ears were clinically evaluated as normal. Audiometric testing performed at that time revealed the following pure tone thresholds, in decibels: 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear -10 (5) -10 (0) 0 (10) 10 (20) 10 (15) Left Ear 15 (30) 0 (10) 5 (15) 5 (15) 0 (5) In a September 1965 examination the Veteran's ears were clinically evaluated as normal. Audiometric testing performed at that time revealed the following pure tone thresholds, in decibels: 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 0 (15) -10 (0) -5 (5) -5 (5) 0 (5) Left Ear 0 (15) -10 (10) 5 (15) 5 (15) 0 (5) A May 1969 examination again showed that the Veteran's hearing was 15/15 with whispered voice test. The ears were also clinically evaluated as normal. In a February 1970 examination the Veteran's ears were clinically evaluated as normal. Audiometric testing performed at that time revealed the following pure tone thresholds, in decibels: 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 0 5 10 10 10 Left Ear 5 5 5 15 15 In an August 1972 examination the Veteran's ears were clinically evaluated as normal. Audiometric testing performed at that time revealed the following pure tone thresholds, in decibels: 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 5 5 5 5 5 Left Ear 5 5 0 15 5 In an August 1974 separation examination the Veteran's ears were clinically evaluated as normal. Audiometric testing performed at that time revealed the following pure tone thresholds, in decibels: 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 5 10 10 15 20 Left Ear 5 5 5 15 5 The Veteran submitted a claim for service connection for bilateral hearing loss in May 2008. In connection with his claim, the Veteran was afforded a VA audiological examination in September 2008. In the audiological evaluation report, the VA examiner noted that the Veteran's claims file was available and reviewed. Audiometric testing performed at that time revealed the following pure tone thresholds, in decibels: 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 35 40 70 80 Left Ear 40 40 50 70 Puretone Threshold Average of 1000 Hz - 4000 Hz Right Ear 56 Left Ear 50 Speech Recognition Right Ear 75% Left Ear 85% The September 2008 VA examiner diagnosed a mild sloping to severe sensorineural hearing loss for the right ear and a mild sloping to severe sensorineural hearing loss for the left ear. The examiner noted that the Veteran's February 1955 enlistment examination showed "normal" hearing based on the Veteran's ability to hear whispered speech at a certain distance. However, the examiner noted that this form of testing cannot be considered reliable. Notably, the examiner wrote that even severe levels of high frequency hearing loss are often not detected by this form of test. Thus, it was not possible to rule out the presence of hearing loss either at the time of the enlistment. Despite this, the examiner wrote that there was no significant reason to suspect pre-service hearing loss. The examiner also wrote that the Veteran's 1974 "transfer to the reserves" physical showed normal hearing thresholds in both ears at all test frequencies used to determine VA hearing disability. Because the Veteran's hearing thresholds were within normal limits at all frequencies used to determine VA hearing disability at the time of his separation, the examiner opined that the Veteran's current binaural hearing loss was less likely than not related to or caused by his military noise exposure. As above, the Veteran testified during the August 2013 Board hearing that he worked on the flight deck of an aircraft carrier in close proximity to noisy aircraft and did not use hearing protection. Also, during the August 2013 hearing the Veteran's brother, F.D.G., testified he and his brother were stationed at Barber's Point in Hawaii together between 1961 and 1963, at which time, it was apparent that the Veteran's hearing "wasn't worth a dime because his wife and those of us around him we used to tell him turn down the television because he'd have it so doggone loud." After the August 2013 hearing the Veteran submitted a statement from Dr. R.G.L., his treating physician. In this statement Dr. R.G.L. wrote that he had reviewed the Veteran's service history and noted that the Veteran had served for an extended period of time and worked on the flight deck of several aircraft carriers in his naval career. The time periods of his service spanned two decades, from 1955 to 1972. His service transcended the Korean conflict and the military action in Vietnam. Hearing protection for prevention or diminution of noise induced hearing impairment evolved over these decades but the exposure to industrial/military noise over time has caused significant damage for thousands of service men and women, like the Veteran, over these same years. Dr. R.G.L. wrote that the Veteran's hearing loss showed a sloping moderate to severe sensorineural impairment with a notching effect in the higher frequencies. This was classically consistent with noise damage known as "Noise Induced Hearing Impairment." Reviewing the Veteran's service and work duties around the flight activity of several carriers, and the examination results, the Dr. R.G.L. opined that the Veteran's in-service noise exposure was, more likely than not, a major causative factor in the Veteran's current long-standing hearing impairment. Initially, the Board accepts that the medical evidence of record shows that the Veteran meets the requirements of 38 C.F.R. § 3.385 for hearing loss disability. Further, after reviewing the evidence of record, the Board finds that when resolving the benefit of the doubt in favor of the Veteran, service connection for bilateral hearing loss is warranted. The record shows that the Veteran was likely exposed to a high level of noise over many years while in service given his military occupational specialty of a flight attendant. Further, a standard threshold shift did occur in the right ear during service as evidenced by the August 1972 and August 1974 service examinations (i.e., from 5 to 20 dBL at 4000 Hz and from 5 to 15 dBL at 3000 Hz). Although the September 2008 VA examiner found that the Veteran's hearing loss was not related to service, the Board finds that this opinion is insufficient because it did not provide an adequate rationale beyond finding normal hearing at discharge. Moreover, the September 2008 VA examiner did not address the threshold shift documented in service. If there is acoustic trauma due to significant noise exposure in service as well as an upward shift in tested thresholds in service, and post-service hearing loss findings meeting the requirements of 38 C.F.R. § 3.385, it must be considered whether there is a medically sound basis to attribute the current hearing loss to the injury in service. See Hensley, (cited above). The August 2013 opinion from Dr. R.G.L. is much more probative. Significantly, Dr. R.G.L. wrote that the Veteran's hearing loss showed a sloping moderate to severe sensorineural impairment with a notching effect in the higher frequencies which was classically consistent with noise damage known as "Noise Induced Hearing Impairment." Dr. R.G.L. also reviewed the Veteran's service and work duties around the flight activity of several carriers and opined that the Veteran's in-service noise exposure was, more likely than not, a major causative factor in the Veteran's current long-standing hearing impairment. Moreover, the Veteran has also consistently reported that he has had ongoing hearing problems since service. Lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Citing Buchanan and Jandreau, the Federal Circuit recently reiterated that it had previously and explicitly rejected the view that competent medical evidence is required when the determinative issue in a claim for benefits involves either medical etiology or a medical diagnosis. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). As such, there is evidence of continuity of symptoms since service. See Walker, (cited above). In sum, based on the analysis above, given the evidence of noise exposure in service as well as a threshold shift in the right ear during service, the August 2013 positive nexus opinion, and medical evidence of current bilateral hearing loss in accordance with VA regulations, the Board finds that when resolving the benefit of the doubt in favor of the Veteran, service connection for bilateral hearing loss is warranted. The Board notes that in reaching this conclusion, the evidence is at least in equipoise, and the benefit of the doubt doctrine has been applied where appropriate. See 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Diabetes Mellitus and Coronary Artery Disease The governing law provides that a "veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975 shall be presumed to have been exposed during such service to an herbicide agent . . . unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service." 38 U.S.C.A. § 1116(f). VA regulations provide that, if a veteran was exposed to an herbicide agent during active service, presumptive service connection is warranted for several disorders, to include diabetes mellitus and ischemic heart disease (including, but not limited to, atherosclerotic cardiovascular disease including coronary artery disease). 38 C.F.R. § 3.309(e); See also 75 Fed. Reg. 53,202 (Aug. 31, 2010). "Service in the Republic of Vietnam," includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii). The VA General Counsel has determined that the regulatory definition (which permits certain personnel not actually stationed within the borders of the Republic of Vietnam to be considered to have served in that Republic) requires that an individual actually have been present within the boundaries of the Republic. See VAOPGCPREC 27-97. Specifically, the General Counsel has concluded that in order to establish qualifying "service in Vietnam" a veteran must demonstrate actual duty or visitation in the Republic of Vietnam. In this case, the Veteran's private treatment records show a diagnosis of diabetes mellitus as early as May 1998. Private treatment records also show an impression of coronary artery disease as early as August 2001. He filed a claim for service connection for diabetes mellitus and coronary artery disease in May 2008. The Veteran contends that he was exposed to herbicide and Agent Orange in Vietnam. He received several awards and commendations to include the Republic of Vietnam Meritorious Unit Citation with Palm and the Vietnam Gallantry Cross. His military occupational specialty is listed as flight attendant. A June 2008 PIES response requesting that dates of any Vietnam service for the Veteran be furnished shows that they were unable to determine whether or not the Veteran served in the Republic of Vietnam. The Veteran was attached to a unit (Fighter Squadron 194) which could have been assigned to a ship or shore. For DoD (Department of Defense) purposes, the unit was credited with Vietnam service from January 25, 1968 to March 4, 1968; March 25, 1968 to April 8, 1968; April 16, 1968 (one day only); April 24, 1968 to May 12, 1968; May 20, 1968 to June 14, 1968; June 25, 1968 to July 23, 1968; May 16, 1969 to June 3, 1969; June 16, 1969 to June 30, 1969; July 13, 1969 to July 31, 1969; August 16, 1969 to September 18, 1969; and October 8, 1969 to October 31, 1969. However, the Veteran's service record provides no conclusive proof of in-country Vietnam service; luckily, conclusive proof is not required In connection with his claim the Veteran submitted statements from E.R.B. (a fellow service-member) and F.D.G. (the Veteran's brother). In a July 2008 statement, E.R.B. wrote that he was a U.S. Army Captain assigned to the 245th Aviation Company (AS) from December 1968 to June 1969 as an OV-1 Mohawk pilot and Standardization Instructor Pilot (SIP), at Marble Mountain, Republic of South Vietnam. He was then assigned as Commander, HHC, 212th Aviation Battalion from mid-June 1969 to December 1969, which was also located at Marble Mountain. He continued to fly regular combat missions with the 245th Aviation Company during this time. E.R.B. that he received a call from F.D.G., 131st Aviation Company, located at Hue Phu Bai, asking if he could pick up the Veteran (F.D.G.'s brother), from DaNang Airbase. E.R.B. wrote that the Veteran was in the Navy and had flown to DaNang from the ship on which he was stationed that was located off the coast of South Vietnam. F.D.G. asked E.R.B. if he would give his brother a check out on the Martin-Baker ejection seat that was in the Mohawk. The Veteran was going to fly to Hue Phu Bai in a Mohawk and then fly a combat mission before returning to his ship. E.R.B. was unsure of the exact date, but a sergeant and himself drove a jeep to DaNang, picked up the Veteran, and returned to Marble Mountain. E.R.B. completed the Veteran's orientation check out in the Martin-Baker ejection seat. Later that day, a Mohawk from the 131st Aviation Company picked the Veteran up and flew him back to Hue Phu Bai. In a July 2008 statement F.D.G. wrote that, during the period of December 1968 to December 1969, he was stationed at Hue Phu Bai, Republic of South Vietnam. His unit of assignment was the 131st Aviation Company (AS). He was a Captain in the U.S. Army assigned as an aircraft pilot flying the OV-1 Mohawk aircraft. During his assignment at Hue Phu Bai, he was visited by his brother, the Veteran, who was in the U.S. Navy stationed aboard an aircraft carrier in the Gulf of Tonkin. He flew into F.D.G.'s location at Hue Phu Bai and remained for approximately three days. One of the aircraft from F.D.G.'s unit had flown to Marble Mountain Army Air Field, RVN (Republic of Vietnam), to pick him up. During the Veteran's stay, he was able to fly one combat mission with F.D.G. at the controls. He was returned to Marble Mountain Army Air Field, again in one of the aircraft from F.D.G.'s unit. F.D.G. could not recall the exact dates of the Veteran's stay with his unit at Phu Bai, however, he believed that this was during the mid months of 1969. CWO-2 Barthalome flew the Veteran into Phu Bai and F.D.G. flew him back to Marble Mountain. In September 2008 correspondence and during the August 2013 Board hearing the Veteran testified that he was at the DaNang Air Force Base for approximately 30 days in 1969. He contended that he was part of a four-man maintenance team that was sent there to service an aircraft that was having problems. During this time he visited his brother in Phu Bai. The Veteran testified that the Navy awarded him the Vietnam Cross of Gallantry for taking this crew in and repairing the aircraft. In this case, resolving all reasonable doubt in favor of the appellant, the Board finds that the Veteran set foot in Vietnam in 1969 and is entitled to service connection for diabetes mellitus and coronary artery disease on a presumptive basis. 38 U.S.C.A. § 5107(b). The Veteran was attached to a unit (Fighter Squadron 194) which could have been assigned to a ship or shore in Vietnam. The Veteran gave sworn testimony during the August 2013 Board Videoconference heading that he visited Vietnam during his military service in 1969. Furthermore, the July 2008 statements from E.R.B. and F.D.G. provide a plausible basis to conclude that the Veteran actually set foot in Vietnam in 1969. Notice and Assistance A discussion addressing whether VA's duties to notify and assist the Veteran have been complied with regarding the above issues is not warranted. To the extent necessary, VA has fulfilled its duties to notify and to assist the Veteran in the development of these issues. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002). In light of the determinations reached in these issues, no prejudice will result to the Veteran by the Board's consideration of these issues at this time. Bernard v. Brown, 4 Vet. App. 384, 393-94 (1993). ORDER Service connection for bilateral hearing loss is granted. Service connection for diabetes mellitus, type II, is granted. Service connection for coronary artery disease is granted. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). With regard to the remaining hypertension, hypercholesterolemia, and vision disorder issues, private treatment records show an impression of hypertension as early as August 2001, an impression of hypercholesterolemia as early as March 2008, and an impression of pseudophakia as early as August 2013. The Veteran testified during the August 2013 Board hearing that he was first diagnosed with hypertension in 1979, with hypercholesterolemia in the mid-1980s, and a vision disorder in approximately 1980. The Board notes that the Veteran has now been granted service connection for coronary artery disease and diabetes mellitus. Significantly, during the August 2013 Board hearing, the Veteran testified that his private physician, Dr. M.M., told him that the he was experiencing changes in his vision due to his diabetes. Furthermore, an August 2013 private treatment record notes what appears to be decreased vision to be secondary to diabetes. This raises the issue as to whether the Veteran's hypertension, hypercholesterolemia, and/or vision disorder are secondary to or aggravated by the Veteran's now service-connected disorders. Initially, the Board notes that the June 2008 letter notified the Veteran of the requirements for obtaining service connection on a direct basis but did not address the requirements for obtaining service connection on a secondary basis. Thus, the Veteran was never adequately informed of the requirements needed to substantiate the remaining claims on appeal. Therefore, the Board has no choice but to remand this appeal to correct this deficiency. Also, the Veteran has not yet been afforded a VA examination with regard to these claims. The Board finds that a medical opinion is necessary to decide these claims. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Specifically, a remand is required in order to afford the Veteran a VA examination so as to determine whether the Veteran's hypertension, hypercholesterolemia, and/or vision disorder are secondary to or aggravated by the Veteran's now service-connected disorders. Moreover, as above, during the August 2013 Board hearing the Veteran testified that he had been treated testified that his private physician, Dr. M.M., for a vision disorder since approximately 1980. Following the hearing, the Veteran submitted an August 2013 private treatment record from Montgomery Lasik & Eye Care Center. As the Veteran claims to have been treated for a vision disorder since 1980 and the earliest records in the claims file are dated in 2013, there appear to be outstanding medical records in this case that should be obtained for consideration in the Veteran's appeal, to include those from Dr. M.M. and/or Montgomery Lasik & Eye Care Center. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). Expedited handling is requested.) 1. Send the Veteran corrective notice informing him of the requirements for establishing entitlement to service connection for a hypertension, hypercholesterolemia, and a vision disorder on a secondary basis. 2. The Veteran should be given an opportunity to identify any healthcare provider who treated him for his hypertension, hypercholesterolemia, and/or vision disorders since service, but to specifically include records from Dr. M.M. and/or Montgomery Lasik & Eye Care Center. After securing any necessary authorization from him, obtain all identified records not already contained in the claims file. All reasonable attempts should be made to obtain any identified records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 3. After obtaining the above records, schedule the Veteran for appropriate VA examination(s) to determine the current nature and etiology of his claimed hypertension, hypercholesterolemia, and a vision disorder. The examiner should answer the following questions: A. Does the Veteran have hypertension, hypercholesterolemia, and/or a vision disorder? B. Did the Veteran's hypertension, hypercholesterolemia, and/or vision disorder have their onset in service; or, are they otherwise related to the Veteran's active military service? C. Did the Veteran's service-connected diabetes mellitus and/or coronary artery disease cause the Veteran to develop either hypertension, hypercholesterolemia, and/or a vision disorder? D. Does the Veteran's service-connected diabetes mellitus and/or coronary artery disease cause an aggravation (permanent worsening) of either the hypertension, hypercholesterolemia, and/or vision disorders beyond their natural progress? If so, the examiner should identify the clinical signs and manifestations of these disorders which establish: (i) the baseline level of severity of the disorders before the onset of aggravation (permanent worsening); (ii) the onset of aggravation (permanent worsening) of these disorders; and (ii) the current level of severity of these disorders at (or after) the onset of aggravation (permanent worsening). The examiner should address the Veteran's reported history of these disorders, to include the Veteran's August 2013 testimony that he was first diagnosed with hypertension in 1979, with hypercholesterolemia in the mid-1980s, and a vision disorder in approximately 1980. The examiner should also address the April 1973 service treatment record which appears to show an assessment of hypertension. In doing so, the examiner must acknowledge the Veteran's competent reports as to the onset and continuity of symptomatology. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the examiner is not able to provide an opinion, he or she should explain why. Since it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1, copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 4. After the above has been completed, the RO must review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action must be implemented. If any report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. 5. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issues on appeal. If the benefits sought on appeal remain denied, in whole or in part, the Veteran should be provided with a Supplemental Statement of the Case and be afforded reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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. 2013). ______________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs