Citation Nr: 1334732 Decision Date: 10/30/13 Archive Date: 11/06/13 DOCKET NO. 08-17 031 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for hepatitis C. 2. Entitlement to service connection for a heart disorder, to include coronary artery disease and congestive heart failure. 3. Entitlement to compensation benefits under 38 U.S.C.A. § 1151 for complications from hernia surgery, including pinched disc in the neck, numbness and tingling in both hands, tingling in the right leg, and cellulitis. 4. Entitlement to an initial compensable evaluation for shrapnel wound of the abdomen. REPRESENTATION Appellant represented by: John S. Berry, Attorney at Law ATTORNEY FOR THE BOARD Suzie S. Gaston, Counsel INTRODUCTION The Veteran had active military service from December 1965 to February 1978; he also had active duty for training from April 16 to August 5, 1964. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Lincoln, Nebraska, Regional Office (RO). By a rating action in August 2007, the RO granted service connection for small shrapnel wound of the abdomen, evaluated as 0 percent disabling. By a rating action in December 2007, the RO denied service connection for hepatitis C and entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for complications from hernia surgery. In a May 2010 decision, the Board denied the Veteran's claims of service connection for hepatitis C, entitlement to compensation benefits under 38 U.S.C.A. § 1151 for complications from hernia surgery, and entitlement to a compensable evaluation for shrapnel wound of the abdomen. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). By a memorandum decision entered in January 2012, the Court vacated the Board's decision on these issues and remanded for readjudication consistent with the memorandum decision. In October 2012, the Board remanded the case for further evidentiary development. The VA Appeals Management Center (AMC) undertook additional development and issued a supplemental statement of the case (SSOC) in February 2013. By a rating action in February 2013, the RO denied a claim of service connection for coronary artery disease. The Veteran perfected a timely appeal to that decision. Although the Veteran initially filed a claim for service connection for coronary artery disease, the Board notes that the Veteran has been diagnosed with congestive heart failure. The Court has determined that the use of the term "condition(s)" in 38 C.F.R. § 3.159(a)(3) indicates that a single claim can encompass more than one condition and that an appellant can reasonably expect that alternative current conditions within the scope of the filed claim will be considered. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Therefore, the Board has recharacterized the issue on appeal as set forth on the title page of this decision to encompass any heart disorder. (The issue of entitlement to service connection for heart disease, including as secondary to diabetes mellitus, is addressed in the remand that follows the decision below.) FINDINGS OF FACT 1. The Veteran's hepatitis C did not have onset in service and it is not otherwise traceable to the Veteran's active military service. 2. The ventral hernia repair resulted in no residual disability. 3. The Veteran's shrapnel wound of the abdomen is manifested by no more than slight impairment. CONCLUSIONS OF LAW 1. The Veteran does not have hepatitis C that is the result of disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). 2. The criteria for compensation benefits pursuant to the provisions of 38 U.S.C.A. § 1151 for complications from hernia surgery have not been met. 38 U.S.C.A. §§ 1151, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159(a), 3.361 (2013). 3. The criteria for an initial compensable rating for shrapnel wound of the abdomen have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.73, Diagnostic Code 5319 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159 , 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of the information and evidence not of record that is necessary to substantiate the claim; and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims has held that VCAA notice should be provided to a claimant before the initial RO decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, if VCAA notice is provided after the initial decision, such a timing error can be cured by subsequent readjudication of the claim, as in a statement of the case SOC or supplemental SOC (SSOC). Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In this case, VA satisfied its duty to notify by means of letters dated in April 2007, May 2007, June 2007, October 2007, and February 2009 from the RO to the Veteran which were issued prior to the RO decisions in August 2007, December 2007, and April 2009, respectively. Additional letters were issued in March 2008, June 2008, and May 2012. Those letters informed the Veteran of what evidence was required to substantiate the claims, and of his and VA's respective duties for obtaining evidence. Accordingly, the requirements the Court set out in Pelegrini have been satisfied. The Board finds that the content of the above-noted letters provided to the Veteran complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. Regarding the duty to assist, the Veteran was provided an opportunity to submit additional evidence. It also appears that all obtainable evidence identified by the Veteran relative to his claims has been obtained and associated with the claims file, and that neither he nor his representative has identified any other pertinent evidence not already of record that would need to be obtained for a proper disposition of the issues addressed herein. It is therefore the Board's conclusion that the Veteran has been provided with every opportunity to submit evidence and argument in support of his claims, and to respond to VA notice. The Board is unaware of any outstanding evidence or information that has not already been requested. The Veteran has been afforded VA examinations on the issues decided herein. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The examinations afforded the Veteran are adequate. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). The examinations were conducted by medical professionals who reviewed the medical records, solicited history from the Veteran and provided finding necessary to adjudicate the issues. Accordingly, the Board finds that VA has satisfied its duty to notify and assist the Veteran in apprising him as to the evidence needed, and in obtaining evidence pertinent to his claims under the VCAA. Therefore, no useful purpose would be served in remanding the questions addressed herein for yet more development. Such a remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit flowing to the Veteran. The Court has held that such remands are to be avoided. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). II. Background The Veteran entered active duty in December 1965. His DD Form 214 indicates that he served as an engineer equipment repairman. He served in Vietnam from September 1, 1966 to May 20, 1968. His military personnel records indicate that he was awarded the Purple Heart, the Vietnam Service Medal w/4 bronze service stars, and the Republic of Vietnam Gallantry Cross w/Palm Unit Citation badge. The service treatment records (STRs) are negative for a diagnosis of hepatitis C or any indication of a liver disorder or other possible symptoms of hepatitis C. Moreover, the Veteran does not contend that he was diagnosed with hepatitis C or treated for symptoms associated with hepatitis C during service. The STRs also were negative for any finding of identifying body marks, including tattoos. VA progress notes dated from July 2006 through October 2006 reflect treatment for epigastric and umbilical hernia. The records indicate that the Veteran was seen at a surgery clinic in September 2006 with complaints regarding a ventral and umbilical hernia, which he stated that he had had for about 40 years. The Veteran stated that the hernia was mildly tender to palpation and that he was able to reduce it. Examination revealed a large herniation in the epigastric region and the umbilicus slightly tender to palpation. The assessment was epigastric and umbilical hernia. The plan was for a laparoscopic surgical repair of the large epigastric and umbilical hernia in November 2006. Received in June 2007 were VA treatment records dated from December 2006 to May 2007. These records indicate that the Veteran was seen in December 2006 for complaints of chest pain. It was noted that the Veteran was seen in surgical evaluation prior to ventral hernia repair; upon questioning, he admitted to some chest pain two weeks ago. It was noted that he was seen by his primary care physician in September 2006 for complaints of chest pain of 5 months duration. He underwent cardiac catheterization on September 27, 2006, showing systolic bridging of mid-LAD with HR. A cardiovascular examination was unremarkable. The assessment was pulmonary hyperinflation. On January 3, 2007, the Veteran presented for ventral hernia repair. He denied recent fevers or illness. He complained of pain at the site of the hernia with exertion. It was noted that the Veteran had a large ventral hernia surrounding the umbilicus with no previous history of abdominal operation. The Veteran signed an informed consent for the surgery--a laparoscopic ventral hernia repair. The Veteran underwent a laparoscopic ventral/umbilical hernia repair. On January 4, 2007, it was noted that the Veteran was doing well; he had increased abdominal distension from prior to surgery. Pain was under control. On January 7, 2007, the Veteran had a full range of motion in all extremities, equal strength bilaterally; he was able to ambulate. On January 11, 2007, the extremities were reported to be within normal limits. When seen on January 12, 2007, the Veteran indicated that he was feeling better. The assessment was post-operative cellulitis complicating ventral hernia repair with mesh. The Veteran was seen for a follow-up evaluation in February 2007; at that time, he stated that he had been having some numbness in his hands and feet and thighs since the surgery. He stated that he was seen at the emergency room and was sent home with a neurologic consultation; however, he had not heard anything from neurology. In a statement in support of claim (VA Form 21-4138), dated in March 2007, the Veteran indicating that he was seeking compensation for shrapnel wounds that he received in Vietnam when he ran over a landmine in a wrecker. The Veteran indicated that he had shrapnel in the abdomen some of which were removed during an operation on January 3, 2007. In another statement in support of claim dated in March 2007, the Veteran requested service connection for a scar to his right thumb. On the occasion of a VA examination in June 2007, the Veteran stated that he was involved in a landmine explosion in Vietnam in 1967, during which he sustained shrapnel to the abdomen. It was noted that, in January 2007, he was admitted to the hospital with a diagnosis of ventral hernia complicated by abdominal cellulitis. It was noted that, on January 3, 2007, the Veteran underwent laparoscopic ventral hernia repair with mesh; and, on January 16, 2007, he underwent fluid collection drainage by interventional radiology. The examiner noted that an examination showed the Veteran to be morbidly obese. There was a very tiny, charcoal looking area above and to the right of the abdomen, which appeared to be shrapnel (gunpowder-like). There appeared to be no metal in the abdomen or chest, and no shrapnel was seen on x-rays in the system. However, there was a small area about the abdomen that looked typical of an old shrapnel injury. The causes of this specific ventral hernia/umbilical hernia appeared to be elusive, especially as to their time of onset. There were no scars present, no residual nerve damage, and motion was not limited. The pertinent diagnosis was shrapnel to the abdomen. The examiner stated that it was unlikely that such a small piece of shrapnel would cause the hernia conditions that the Veteran has had for many years. It was determined that the shrapnel itself was not causing any complaints. The record indicates that the Veteran was seen in July 2007 for evaluation of his complaints of numbness and pain in both arms and right leg. It was noted that the Veteran had abdominal hernia surgery in January 2007 under general anesthesia; and, since then, he had had problems with numbness of both arms and numbness of the right thigh. Since then, however, the Veteran had not been able to return to work as he had difficulty holding onto objects. He complained of severe burning pain in both arms up to the shoulders but worse in the hands. The assessment was pain and numbness in both arms and right leg. The etiology of his neuropathy was unclear. He stated that it was unlikely to be related to the surgery although symptoms started right after that. In July 2007, the Veteran's claims folder was referred to a VA examiner for a medical opinion. Following review of the evidence of record, including the Veteran's statements, hospital discharge summary, and surgical/operative reports regarding the ventral hernia repair performed on January 3, 2007, the examiner stated that there was no evidence of carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on the part of VA in furnishing medical care in connection with the ventral hernia repair surgery. The indication for the Veteran's surgery was clear, and surgeries were performed without complications due to any errors or lack of judgment. The physician further noted that, review of all evidence of record in connection with the hernia repair reveals that care provided regarding the hernia condition was well within established standards of medical care. The physician explained that, although unfortunate, postoperative infection/cellulitis can be a potential, unfavorable outcome of any surgical procedure. Regarding the Veteran's neurological complaints, which began following surgery, the physician stated that a review of the records note that there had been no determination of a specific causal relationship of his symptoms and his laparoscopic hernia repair. In October 2007, the Veteran was seen for complaints of burning pain, numbness in both upper extremities and legs. He was seen in a GI clinic in November 2007 with a history of hepatitis C, genotype I and with viremia and normal transminases; it was noted that risk factors included blood transfusion in 1968. It was also noted that the Veteran did have a tattoo but this was obtained 5 years earlier. He had no history of IV or INDU, no dialysis, no known sexual exposure. The Veteran indicated that he did not drink alcohol. (He had a history of PTSD with depression under good control at the time; however, he did have suicidal ideations at times. He had flashbacks to Vietnam at night and sometimes became aggressive in his sleep.) The assessment was hepatitis C genotype I. Received in March 2008 were VA progress notes dated from November 2007 to March 2008. These records reflect treatment primarily for a psychiatric disorder. A January 2008 VA progress note reflects that the Veteran was seen for complaints of left-sided abdominal wall pain, aggravated by motion. The assessment was torn abdominal muscle, doubt hernia. Private treatment reports dated in January 2009 reflect diagnoses of diabetes mellitus and neuropathy. Received in June 2009 were VA progress notes dated from February 2009 to June 2009. These records show that the Veteran continued to receive clinical attention for diabetes mellitus and hepatitis C. These records do not reflect any complaints, diagnoses, or treatment for heart disease. Received in May 2010 were VA progress notes dated from June 2009 to May 2010. These records show that the Veteran continued to receive clinical attention for diabetes mellitus and hepatitis C; he also received emergency treatment for complaints of abdominal pain. A GE outpatient treatment note, dated in December 2009, indicates that the Veteran was seen for a routine follow-up evaluation of his hepatitis C, genotype I and with viremia and normal transaminases. The impressions were cirrhosis and hepatomegaly and splenomegaly. The Veteran was seen by his primary care physician in February 2010 with complaints of increased leg swelling. The assessment was right-sided heart failure, obesity, cirrhosis, and dietary non-compliance, all contributing to leg edema. A March 2010 treatment note reported a past medical history of hepatitis C, contracted by blood treatment in 1968. The impression was hepatitis C with high viral load and normal transaminases as well as normal intrinsic liver function. It was noted that the Veteran had normal liver function tests with fatty liver versus cirrhosis. This treatment report also noted that there was no known history of coronary artery disease. Received in June 2010 were VA progress notes dated from May 2010 to June 2010. These records do not reflect any complaints or treatment for hepatitis C, heart disease, or shrapnel wounds to the abdomen. Also received in June 2010 were VA progress notes dated from September 2006 to March 2010. These records show that the Veteran was seen in September 2006 for complaints of chest pain; the Veteran indicated that he started feeling the pain after getting up and it got progressively worse during the day. It was noted that the Veteran had had hypertension for many years and he was morbidly obese; he also had a possible family history of heart disease. Following an evaluation, it was noted that the chest pain could be due to angina, but it could also be caused by heartburn or muscle strain. The Veteran was prescribed Nitroglycerin. An addendum, dated September 18, 2006, reflects an assessment of fixed defect inferior/apical walls, with possible reversible component, and inferior wall hypokinesis. In November 2012, the Veteran's claims folders were referred to a VA examiner for review and opinion regarding the etiology of the claimed hepatitis C and other liver conditions. The examiner noted that the Veteran has been diagnosed with hepatitis C. The examiner observed that the Veteran was a somewhat difficult historian with regards to the accuracy of his statements. The examiner noted that the Veteran described that he believed he was first diagnosed with hepatitis C approximately 10 years ago in the 2002-2003 timeframe, although he could find no evidence of hepatitis being diagnosed or documented in the Veteran prior to 2006. The examiner also noted that the Veteran was describing some subjective fatigue, although he was not describing the acute onset of fatigue that was resulting in decreased inactivity or energy level of 50 percent and more. The Veteran also reported some generalized abdominal pain that occurs up to two to three times a week that can last hours in duration. The Veteran also stated that there can be some associated nausea. He was somewhat vague in his description of the condition. He stated that he has told his providers that he has intermittent abdominal pain. It was noted that the Veteran was morbidly obese. He had undergone an ultrasound of the abdomen in the past that demonstrated no hepatic masses or lesions, but does demonstrate a heterogeneous nodular liver that was consistent with underlying parenchymal disease. He also had splenomegaly. The examiner also noted that the Veteran had a history of congestive heart failure that can result in some probable etiology of abdominal pain. The Veteran reported that he had no IV drug use, no known sexual exposure, cocaine use, or history of shared toothbrushes or razors. The Veteran indicated that he had a blood transfusion while in Vietnam in the 1968 timeframe. The Veteran stated that the blood transfusion was due to injuries sustained that included injury to the right hand and to the forehead. The examiner noted that the Veteran had a scar to the right hand of the thenar eminence and also had a superficial scar to the forehead. The examiner stated that he reviewed the Veteran's claims file and found no specific documentation in his STRs that report any surgeries or blood transfusions with regards to the right hand, the scalp or forehead. The examiner noted that there was no mention or suggestion that the sutured repair of the right hand required any significant surgical repair and certainly not to the scope that would likely require operative procedure that included a blood transfusion. Furthermore, a laceration involving the forehead is not a wound that would likely require the need for a blood transfusion, although the Veteran recalled IV bags and felt that blood was involved in his treatment. Although the Veteran believed that he was treated with a blood transfusion, the examiner found no documented evidence of a blood transfusion for any of his wounds that occurred while on active military duty in Vietnam, and review of the wounds themselves tended to the make the examiner believe that it was not likely that the nature and extent of the wounds as he demonstrates and has described would have likely required the need for a blood transfusion as part of the treatment procedure, primarily the wound to the right hand and the forehead. The examiner also noted that the Veteran had shrapnel wounds to the abdomen, and this was a very superficial scar that did not likely result in any bleeding. The Veteran demonstrated no wound of the abdomen that would have likely required any blood transfusion. The examiner noted that the Veteran had tattoos to the left forearm, as well as to the right upper arm. The Veteran reported getting those tattoos while in Vietnam; however, during a clinical visit in September 2007, the Veteran reported that the tattoos were done only five years prior to the examination. The examiner stated that, if the Veteran received the dark inked tattoos that he had on his left forearm and right forearm while in Vietnam, it would be more likely that he had exposure to hepatitis C by way of those tattoos than it was likely that he had received a blood transfusion and received hepatitis C by that route. The examiner again noted that the Veteran did not describe any other well-known risk factors that would lend favor in accurately pinpointing the etiology of his hepatitis C or the mechanism of exposure. He reiterated that the Veteran did have some wounds while on active duty in Vietnam, and although it is possible that he was exposed to hepatitis C at that time, it would require resorting to mere speculation to state with any accuracy as to precisely when the Veteran was exposed to hepatitis C, and thus became infected. The only degree of accuracy is the fact that he did undergo blood testing for hepatitis C in 2006 and that in 2006 it was identified that he did in fact test positive for hepatitis C, indicating that he was exposed to hepatitis C and became infected with hepatitis C virus sometime prior to 2006. Again, the examiner stated that it would require resorting to speculation to determine with any degree of accuracy when in fact he did become infected with hepatitis C, although it was his opinion that it was likely that his tattoos represent the most likely risk factor, given the Veteran's history with regards to him coming in contact with hepatitis C and ultimately becoming infected with hepatitis C. The Veteran was also afforded a VA examination for evaluation of the shrapnel fragment wound to the abdomen. The examiner noted that the Veteran had a 2.5 mm darkened area to the anterior aspect of the midline of the abdomen that likely represents shrapnel fragment wound with some degree of retained shrapnel. There was no associated tenderness, but the dark lesion was present. The examiner noted that this was a very superficial wound and the Veteran did not require any surgical intervention regarding his wound and only required simple minor wound care at the time of the injury. At the time of the examination, there was no pain, tenderness or other symptoms. The examiner noted that the Veteran was morbidly obese and had a somewhat prominent abdomen, and the shrapnel fragment wound of a superficial nature was visible and again measured approximately 2.5 mm in diameter. There was no pain or tenderness. There was no skin breakdown. There were no symptoms requiring any medication, treatment or therapy. The condition did not result in any functional limitation or decrease in range of motion. There was no muscle involvement regarding this injury; therefore, no associated muscle dysfunction due to shell fragment wound of the abdomen. With respect to the claim for compensation under the provisions of 38 U.S.C.A. § 1151, it was noted that the Veteran did undergo a laparoscopic ventral hernia repair on January 3, 2007 at a VA medical center. The Veteran reported that, while in the hospital, after awakening from surgery of the ventral hernia repair, he first noted some paresthesia, numbness and tingling affecting the left arm. It was felt that it may have been the IV, and the IV was removed and a PICC line was placed to the right arm. The Veteran indicated that he subsequently developed some numbness, tingling and paresthesia affecting the right upper extremity. He stated that, once he was able to get up and ambulate, he noticed that he was experiencing some numbness, tingling and paresthesia primarily affecting the right anterior thigh. The Veteran subsequently underwent evaluations, including EMG studies and neurological evaluations, and it was determined that the Veteran did demonstrate some evidence of meralgia paresthetica, as well as nerve entrapment of the upper extremity including carpal tunnel syndrome, as well as some degree of ulnar neuropathy or cubital tunnel syndrome. There was also some degree of cervical spine pathology due to cervical spine disk disease. The examiner stated that it was felt that the symptoms of the paresthesia including cubital tunnel syndrome, meralgia paresthetica and cervical spine disk disease, all of which indicate some nerve entrapment that are not due to, a result of, or caused by any carelessness, negligence, lack of proper skill, or error in judgment or similar signs of fault that may have occurred in the Veteran's treatment for his ventral hernia for which he underwent surgical repair. Although it is interesting that the onset of these symptoms seem to have become apparent following the surgical intervention, there was no evidence to conclude or to support that the surgery or the treatment of the ventral hernia in any way caused or resulted in these nerve entrapments that were causing his symptoms. It was noted that the Veteran speculates that, during the procedure, which he states took longer than may have been expected, he was not properly turned or moved or did not have proper padding in place. However, the examiner reviewed the notes that documented that the elbows and bony prominence were padded, that the blankets were not wrinkled underneath the Veteran during the procedure, and that he did have proper turning and moving throughout the surgical procedure. Therefore, the examiner stated that there was no evidence to conclude that there was any negligence or carelessness on the part of the VA that resulted in the Veteran's current symptomatology. It was the examiner's opinion that it is less likely as not that the Veteran's current neurological symptoms after the surgery were the result of any carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing the medical treatment and care regarding his ventral hernia repair. In an addendum to the above examination pertaining to the shrapnel wound to the abdomen, dated in January 2013, the VA examiner stated that there was no evidence at present that the Veteran had any retained foreign body, but the residual scar or darkened area to the anterior aspect of the midline abdomen likely represented a residual status post shrapnel fragment wound with previously retained shrapnel fragment that had since surfaced and was no longer retained. It was the examiner's opinion that, based on the previous examination of the Veteran, the nature of the wound, the nature of the residual scar status post wound, and the Veteran's own history and account of the wound and course of the condition, it was less likely as not that the Veteran had any currently retained foreign body or shrapnel fragments. The described residual status post shrapnel fragment wound primarily included only the small superficial and essentially asymptomatic scar as described in the November 2012 evaluation and examination report. The examiner again noted that, based on the previous examination, history of condition, and review of all available records, there was no evidence to support that the Veteran had any currently retained shrapnel or retained foreign body to the abdomen status post previous shrapnel fragment wound that occurred while on active military duty. Furthermore, abdominal x-ray performed in September 2010 revealed no evidence of retained foreign body or other radiographic evidence consistent with retained shrapnel fragment of the abdomen. III. Service Connection Service connection is warranted for disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C. §§ 1110, 1131. To establish a right to compensation for a present disability, a claimant 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"--the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Holton v. Shinseki, 557 F.3d 1362 (2009). The Veteran can attest to factual matters of which he has first-hand knowledge, such as experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a lay person is competent to identify the medical condition (noting that sometimes the lay person will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether the evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21. Vet. App. 303 (2007). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the veteran. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), it was observed that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Veteran claims entitlement to service connection for Hepatitis C. Medically recognized risk factors for hepatitis C include: (a) transfusion of blood or blood product before 1992; (b) organ transplant before 1992; (c) hemodialysis; (d) tattoos; (e) body piercing; (f) intravenous drug use (with the use of shared instruments); (g) high-risk sexual activity; (h) intranasal cocaine use (also with the use of shared instruments); (i) accidental exposure to blood products as a healthcare worker, combat medic, or corpsman by percutaneous (through the skin) exposure or on mucous membrane; and (j) other direct percutaneous exposure to blood, such as by acupuncture with non-sterile needles, or the sharing of toothbrushes or shaving razors. See VBA Training Letter 211A (01-02), dated April 17, 2001. The regulations provide that, in considering claims of veterans who engaged in combat during campaigns or expeditions, satisfactory lay or other evidence of incurrence or aggravation in such combat of an injury or disease, if consistent with the circumstances, conditions or hardships of such service, will be accepted as sufficient proof of service connection, even when there is no record of incurrence or aggravation. 38 U.S.C.A. § 1154(b) (West 2002). However, section 1154(b) does not create a statutory presumption that a combat veteran's alleged disease or injury is service connected. Collette v. Brown, 82 F.3d 389, 392 (Fed. Cir. 1996). Rather, it aids the combat veteran by relaxing the adjudicative evidentiary requirements for determining what happened in service. Id. The Veteran contends that his current diagnosis of hepatitis C is related to in-service combat wounds. As indicated, because the Veteran is in receipt of the Purple Heart Medal, a wound during combat against the enemy has been demonstrated. In addition to the general statutory and regulatory legal authority governing service connection claims, a VA Fast Letter issued in June 2004 (FL 04-13, June 29, 2004) identified "key points" that included the fact that hepatitis C is spread primarily by contact with blood and blood products, with the highest prevalence of hepatitis C infection among those with repeated, direct percutaneous (through the skin) exposure to blood (i.e., intravenous drug users, recipients of blood transfusions before screening of the blood supply began in 1992, and hemophiliacs treated with clotting factor before 1987). It was concluded in FL 04-13 that the large majority of hepatitis C infections can be accounted for by known modes of transmission, primarily transfusion of blood products before 1992, and injection drug use. After a review of all the evidence in the Veteran's claims file, the Board finds that the preponderance of the evidence is against the claim for service connection for hepatitis C. The weight of the evidence demonstrates that the Veteran did not have any in-service risk factors that are recognized as creating a high risk of hepatitis infection. The Veteran's service treatment records do not document activities that are recognized as creating a high risk of hepatitis infection, e.g., blood transfusion, tattoos, intravenous drug use or promiscuous sexual activity. Although not required to establish a claim for service connection, but as some evidence that tends to weigh against the claim, there is also no in-service diagnosis or treatment of hepatitis C. As noted above, the Veteran is competent to describe what he has personally experienced, including receiving inoculations in service. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, competency is a separate and distinct determination from credibility. Here, the Board does not find the Veteran to be a credible historian. As noted above, the crux of the Veteran's claim is the assertion that he contracted hepatitis C as a result of blood transfusion he received during service in Vietnam, before 1992; the Veteran contends that he was given a blood transfusion as part of his treatment for wounds received in Vietnam. The records indicate that the Veteran sustained a laceration to the right thumb and shrapnel to the abdomen during service, and the STRs confirm that he was treated for the laceration; however, there is no indication in any of the records that the Veteran received a blood transfusion. In fact, in November 2012, following a review of the claims folders, a VA examiner found no documented evidence of a blood transfusion for any of the wounds that occurred while on active military duty in Vietnam, and the nature of the wounds themselves made the examiner believe that it was not likely that there would have been a need for a blood transfusion as part of the treatment. The examiner also noted that the Veteran had shrapnel wound to the abdomen, but this was a very superficial one that did not likely result in any bleeding. He noted that the Veteran demonstrated no wound of the abdomen that would have likely required any blood transfusion. Given these assessments, and especially the lack of evidence showing a transfusion, the Veteran's assertions that he had a blood transfusion during service are not believable. Moreover, the Veteran is also not credible with respect to when he received the tattoos, which have been considered a likely source of the hepatitis C infection. In November 2012, a VA examiner stated that it would require resorting to speculation to determine with any degree of accuracy when in fact the Veteran did become infected with hepatitis C, although it was his opinion that it was likely that the tattoos represented the most likely risk factor, given the Veteran's history with regards to him coming in contact with hepatitis C and ultimately becoming infected. While the Veteran reported at a November 2012 examination for the purpose of obtaining compensation that he got the tattoos while in Vietnam, during a previous clinical visit in September 2007, the Veteran reported that the tattoos were done only five years prior to the examination (in 2002). In light of the foregoing, the Board finds that the weight of the evidence is against the claim for service connection for Hepatitis C. As noted above, the STRs are void of treatment for or diagnoses of hepatitis C and do not show a transfusion. Post-service medical evidence shows that the Veteran was diagnosed with hepatitis C in January 2007. As clearly explained by the VA examiner in November 2012, the evidence does not show that the Veteran received a blood transfusion during service. The Board finds it highly unlikely that something as significant as a blood transfusion would have been omitted from the surgical summary report. Again, the Veteran was not diagnosed with or treated for hepatitis C until January 2007. In fact, a November 2007 GI clinic note indicates that the Veteran had a history of hepatitis C; it was stated that risk factors included blood transfusion in 1968. It was noted that he had had a tattoo but this was obtained just 5 years earlier. He had no history of IV or INDU, no disability, and no known sexual exposure. The Veteran's current hepatitis C is not shown to be due to any event or incident of the Veteran's period of active duty. There is no competent evidence of etiological connection between his military service and his hepatitis C. In addition to not having any in-service risk factors, the Board finds that service connection must be denied because a Veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000); Collaro v. West, 136 F.3d 1304, 1308 (Fed. Cir. 1998). In this case, the Veteran has not submitted any competent evidence of etiological connection between his military service and his hepatitis C. As noted above, the Veteran is not found to be credible regarding the history of transfusion or tattooing during service, and it appears that the most likely cause was his obtaining a tattoo after service. There is no competent evidence of a relationship between the Veteran's diagnosis of hepatitis C and his military service. While the Veteran believes he contracted this disease from a blood transfusion in service, the evidence does not indicate that he received a blood transfusion in service. As noted above, the record suggests a post-service risk factor for hepatitis C, and there is no competent opinion to show that the hepatitis C is related to service. As such, the evidence preponderates against the Veteran's claim, and it must be denied. IV. 38 U.S.C.A. § 1151 The law provides that compensation may be paid for a qualifying additional disability or qualifying death, not the result of the Veteran's willful misconduct, caused by hospital care, medical or surgical treatment, or examination furnished the Veteran when the proximate cause of the disability or death was: (A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or (B) an event not recently foreseeable. 38 U.S.C.A. § 1151. The regulations provide that benefits under 38 U.S.C.A. § 1151(a) for claims received by VA on or after October 1, 1997, as in this case, for additional disability or death due to hospital care, medical or surgical treatment, examination, training and rehabilitation services, or compensated work therapy program, require actual causation not the result of continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished, unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. The additional disability or death must not have been due to the Veteran's failure to follow medical instructions. 38 C.F.R. § 3.361 (2013). It must be shown that the hospital care, medical or surgical treatment, or examination caused the Veteran's additional disability or death, and that (i) VA failed to exercise the degree of care that would be expected of a reasonable health-care provider or that (ii) VA furnished the hospital care, medical or surgical treatment, or examination without the Veteran's or, in appropriate cases, the Veteran's representative's informed consent. To establish the proximate cause of an additional disability or death, it must be shown that there was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination. Whether the proximate cause of a Veteran's additional disability or death was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health-care provider would have foreseen. 38 C.F.R. § 3.361(d) (2013). In determining whether additional disability exists, the veteran's physical condition immediately prior to the beginning of the hospital care, medical or surgical treatment, or other incident in which the claimed disease or injury was sustained (i.e., medical examination, training and rehabilitation services, or work therapy), is compared to the veteran's condition after such treatment, examination or program has stopped. See 38 C.F.R. § 3.361(b). Provided that additional disability is shown to exist, the next consideration is whether the causation requirements for a valid claim have been met. In order to establish actual causation, the evidence must show that the medical or surgical treatment resulted in the Veteran's additional disability. See 38 C.F.R. § 3.361(c)(1). Furthermore, the proximate cause of the disability claimed must be the event that directly caused it, as distinguished from a remote contributing cause. In order for additional disability to be compensable under 38 U.S.C.A. § 1151, the additional disability must have been actually caused by, and not merely coincidental to hospital care, medical or surgical treatment, or medical examination furnished by a VA. Loving v. Nicholson, 19 Vet. App. 96, 100 (2005). In order for additional disability to be compensable under 38 U.S.C.A. § 1151, the additional disability must have been the result of injury that was part of the natural sequence of cause and effect flowing directly from the actual provision of "hospital care, medical or surgical treatment, or examination" furnished by VA and that such additional disability was directly caused by that VA activity. Id at 101. Upon consideration of the evidence of record, the Board finds that the preponderance of the evidence is against the Veteran's claim for benefits under the provisions of 38 U.S.C.A. § 1151 for complications from hernia surgery, including pinched disc in the neck, numbness and tingling in both hands, tingling in the right leg and cellulitis, resulting from a ventral hernia repair in January 2007. As noted above, § 1151 requires proof of causation. In order to be compensable under § 1151, a veteran's additional disability must have actually been caused by hospital care, medical or surgical treatment, or medical examination furnished by a VA employee or in a VA facility. Such is not the case here, and the Veteran's claim fails on that basis. The evidence does not show that there were any additional residuals beyond what is expected from surgery, such as a surgical scar, and the cellulitis. However, there is no indication that the cellulitis resulted in any chronic disability. In July 2007, an opinion was obtained from a VA examiner. The examiner indicated that the claims file was reviewed. The examiner stated that there was no evidence of carelessness, negligence, lack of proper skill, error in judgment or similar instances of fault on the part of VA in furnishing medical care in connection with the ventral hernia repair surgery. The indication for the Veteran's surgery was clear, and surgeries were performed without complications due to any errors or lack of judgment. The physician further noted that, review of all evidence of record in connection with the hernia repair, indicate that care provided regarding the hernia condition was well within established standards of medical care. Although unfortunate, postoperative infection/cellulitis can be a potential, unfavorable outcome of any surgical procedure. More recently, in November 2012, the Veteran's claims folder was referred to a VA examiner for review and opinion regarding the Veteran's claimed neurological symptoms and the link between those symptoms and his ventral hernia surgery. Following a review of the claims folder the examiner opined that it was less likely as not that the Veteran's current neurological symptoms after the surgery were the result of any carelessness, negligence, lack of proper skill, error in judgment, or similar instances of fault on the VA's part in furnishing the medical treatment and care regarding his ventral hernia repair. The examiner noted that the Veteran speculates that, during the procedure, which he states took longer than may have been expected, he was not properly turned or moved or did not have proper padding in place. However, the examiner reviewed the notes that documented that the elbows and bony prominence were padded, that the blankets were not wrinkled underneath the Veteran during the procedure, and that he did have proper turning and moving throughout the surgical procedure. Therefore, the examiner stated that there was no evidence to conclude that there was any negligence or carelessness on the part of the VA that resulted in the Veteran's current symptomatology. The examiner stated that, although it was interesting that the onset of the Veteran's symptoms seem to have become apparent following the surgical intervention, there was no evidence to conclude that the surgery or the treatment of the ventral hernia in any way caused or resulted in these nerve entrapments that were causing his symptoms. In other words, the nerve entrapment, which had nothing to do with the surgery, was merely coincidental-there was no causal relationship. Based on the foregoing, the Board finds that it has not been shown that any additional disability occurred as a result the surgery. The cellulitis resolved and the nerve entrapments were not related to the surgery. Accordingly, the Board finds that entitlement to compensation under 38 U.S.C.A. § 1151 for complications from hernia surgery, including any pinched disc in the neck, numbness and tingling in both hands, tingling in the right leg, and cellulitis is not warranted. As there is a preponderance of the evidence against the claim, the benefit-of-the-doubt rule is not helpful to the claimant. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). V. Higher Rating Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. See 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. Part 4 (2013). When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. A disability rating may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. See 38 C.F.R. § 4.1. In a claim for a higher original rating after an initial award of service connection, all of the evidence submitted in support of the veteran's claim is to be considered. See Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. Staged ratings may be assigned where the symptomatology warrants different ratings for distinct time periods. After review of the evidentiary record, the Board concludes that the Veteran's disability has not changed during the pendency of the claim and a uniform evaluation is warranted. The severity of muscle disability is determined by the type of injury, the history and complaint, and objective findings. 38 C.F.R. § 4.56(d). For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. 38 C.F.R. § 4.56(c). For Diagnostic Codes 5301 through 5323, disabilities resulting from muscle injuries are classified as slight, moderate, moderately severe, or severe. 38 C.F.R. § 4.56. Muscle disability is considered to be slight if it was caused by a simple wound without debridement or infection. The history of a slight muscle disability should include service department records of a superficial wound with brief treatment and return to duty, and healing with good functional results. There should be no cardinal signs or symptoms of muscle disability. Objective findings should include a minimal scar; no evidence of fascial defect, atrophy, or impaired tonus; and no impairment of function or metallic fragments retained in muscle tissue. 38 C.F.R. § 4.56. Muscle disability is considered to be moderate if it was caused by a through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without the explosive effect of a high velocity missile, residuals of debridement, or prolonged infection. The history of a moderate muscle disability should include service department records or other evidence of in-service treatment for the wound as well as a record of consistent complaints of one or more of the cardinal signs and symptoms of muscle disability (loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement), particularly, lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. The objective signs of moderate disability include small or linear entrance and (if present) exit scars, indicating a short track of the missile through muscle tissue, some loss of deep fascia or muscle substance, impairment of muscle tonus and loss of power, or a lowered threshold of fatigue when compared to the sound side. Id. Muscle disability is considered to be moderately severe if it results from a through and through or deep penetrating wound by a small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. The history of a moderately severe muscle injury should include service department records or other evidence showing hospitalization for a prolonged period for treatment of the wound, consistent complaints of the cardinal signs and symptoms of muscle disability as noted above and, if present, evidence of inability to keep up with work requirements. The objective evidence of a moderately severe muscle disability includes entrance and (if present) exit scars that indicate a track of the missile through one or more muscle groups, the loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side, and impairment of strength and endurance in comparison to the sound side. Id. The Veteran's service-connected shrapnel wound of the abdomen has been rated under the criteria for evaluating wounds to muscle group XIX, whose function is support and compression of the abdominal wall and lower thorax; flexion and lateral motions of the spine; and synergists in strong downward motion of the arm. Included in this muscle group are the muscles of the abdominal wall, which includes the rectus abdominis, external oblique, internal oblique, transversalis and quadratus lumborum. A noncompensable evaluation contemplates disability that is slight. A 10 percent evaluation is warranted for a muscle disability that is moderate, while a 30 percent evaluation is in order for a muscle disability that is moderately severe. 38 C.F.R. § 4.73, Diagnostic Code 5319. In an August 2007 rating decision, the RO granted service connection for small shrapnel wound of the abdomen. A noncompensable rating was assigned effective March 29, 2007, under 38 C.F.R. § 4.73, Diagnostic Code 5319. The Veteran contends that the symptomatology associated with his shrapnel wound of the abdomen warrants a compensable rating under Diagnostic Code 5319. In this case, the Board finds that a noncompensable evaluation is warranted under 38 C.F.R. § 4.73, Diagnostic Code 5319. An evaluation of 10 percent is not warranted unless there is evidence of moderate disability. The evidence of record shows that beyond pain, the Veteran has not complained of the cardinal signs and symptoms of muscle disability in relation to his abdominal muscle injury. Furthermore, the evidence shows that the only objectively demonstrated residual from the muscle injury is a minimal scar. Specifically, on VA examination in June 2007, there was a very fine, charcoal looking area above and to the right of the abdomen. There appeared to be no metal in the abdomen, and no shrapnel was seen on x-rays. The examiner stated that the shrapnel wound itself was not causing any complaints. There is no evidence of an entrance or exit scars on the abdomen, and no evidence of loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue. On the occasion of a more recent VA examination in November 2012, the shrapnel fragment wound was described as being superficial in nature and was visible, measuring approximately 2.5 mm in diameter. There was no pain or tenderness. There was no skin breakdown. There were no symptoms requiring any medication, treatment or therapy. The condition does not result in any functional limitation or decrease in range of motion. There was no muscle involvement regarding the injury; therefore, no associated muscle dysfunction due to shell fragment wound of the abdomen. In an addendum in January 2013, the VA examiner stated that it was less likely as not that the Veteran had any currently retained foreign body or shrapnel fragments. The described residual status post shrapnel fragment wound includes only the small superficial and essentially asymptomatic scar as described in the November 2012 evaluation and examination report. The examiner again noted that, based on the previous examination, history of condition, and review of all available records, there was no evidence to support that the Veteran had any currently retained shrapnel or retained foreign body to the abdomen status post previous shrapnel fragment wound that occurred while on active military duty. Furthermore, abdominal x-ray performed in September 2010 revealed no evidence of retained foreign body or other radiographic evidence consistent with retained shrapnel fragment of the abdomen. In short, there has been no muscle injury or associated functional loss by which a compensable rating may be assigned. Nevertheless, the Board has also considered all other potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the Veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board has found no other section that provides a basis upon which to assign a higher disability evaluation or separate compensable evaluation for the disability. There is no indication of a symptomatic scar or other skin problem. Also, there is no suggestion of any loss of function of any other system due to the wound. In summary, for the reasons expressed above, the Board has concluded that the Veteran is not entitled to a compensable rating for his service-connected shrapnel wound of the abdomen. The preponderance of the evidence is against the claim. ORDER Service connection for hepatitis C is denied. Compensation for additional disability from hernia surgery under the provisions of 38 U.S.C.A. § 1151 is denied. Entitlement o an initial compensable evaluation for a shrapnel wound of the abdomen is denied. REMAND The Veteran is seeking service connection for a heart disorder, which he claims developed as a result of his service-connected diabetes mellitus. The law provides that VA shall make reasonable efforts to notify a claimant of the evidence necessary to substantiate a claim and requires VA to assist a claimant in obtaining that evidence. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2013); 38 C.F.R. § 3.159 (2013). Such assistance includes providing the claimant a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2013); 38 C.F.R. § 3.159 (2013). After reviewing the Veteran's claims file, the Board concludes that additional development is necessary in order to comply with VA's duty to notify and assist. See 38 U.S.C.A. §§ 5102, 5103, 5103A. The Veteran asserts that he has a current heart disorder that is etiologically related to his period of active service, to include his service-connected diabetes mellitus. (Although the agency of original jurisdiction appears to have limited the appeal to a claim of service connection for coronary artery disease, in light of the evidence described below and the Veteran's contentions, the Board finds that the appeal is best described as a claim of service connection for any heart disability. Clemons v. Shinseki, 23 Vet. App. 1 (2009).) In order to prevail on the issue of service connection for any particular disability, there must be evidence of a current disability; evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence, or in certain circumstances, lay evidence, of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); 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"). In this case, the record clearly shows that the Veteran has a heart condition, which has been diagnosed as congestive heart failure. The Veteran's claim of entitlement to service connection for coronary artery disease, to include as secondary to diabetes mellitus (VA Form 21-4138) was received in April 2012. Submitted in support of the claim were outpatient treatment reports from the Nebraska-Western Iowa VA healthcare care system, dated from December 2011 to February 2012. The records show that the Veteran underwent an Echocardiogram on February 1, 2012, which revealed normal sinus rhythm, normal left ventricle chamber size and systolic function, and normal right ventricle in size and function. The Veteran was afforded a DBQ examination in June 2012. The examiner noted that the Veteran has been diagnosed with congestive heart failure. The examiner reported that the most recent episode of congestive heart failure was in January 2012. The examiner noted that the Veteran's heart condition does not qualify as an ischemic heart disease (IHD), and the etiology was likely multifactorial. An Echocardiogram was reported to be normal. In February 2013, the Veteran's claims folders were referred to a cardiologist for review and an opinion regarding the presence and etiology of any heart disease. The examiner observed that the "systolic bridging in the mid LAD" noted on the catheterization from some years ago was not indicative or representative of IHD/CAD. The examiner indicated that he discussed this finding with one of the cardiologists. This finding was an anatomical variant and can be genetic and it was not representative of heart disease. In fact, according to the cardiologist, this specific finding did not increase one's risk of having IHD/CAD. The examiner stated that it may bring on some symptoms similar to heart disease, but was not related to coronary artery disease and was not indicative of it. Therefore, this 'bridging' finding was not related to IHD/CAD. The examiner stated that there was no evidence to suggest any aggravation whatsoever. He added that, concerning the diastolic heart failure, because the Veteran had no specific coronary artery disease (based on the cardiac catheterization from some years ago), his diastolic heart failure was not due to coronary disease, because he had none. There was no evidence to suggest aggravation. While the Veteran was afforded a VA examination in November 2012 that assessed his current heart condition, the VA examiner did not address any possible relationship between his current heart condition and his service-connected diabetes mellitus. In light of above, the Board concludes that the Veteran should be provided a VA examination to determine the nature and etiology of his heart disability. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate.) Accordingly, the Board finds that additional VA examination is warranted to determine whether any heart disability, to include congestive heart failure, has been caused or aggravated by service-connected diabetes mellitus. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board also notes that, when the Veteran's representative filed a substantive appeal, he made some comments to suggest that he did not know what was required to substantiate a service connection claim. This should be remedied by further notice. To ensure that VA has met its duty to assist and to ensure full compliance with due process requirements, the case is REMANDED for the following actions: 1. The agency of original jurisdiction (AOJ) should contact the Veteran and obtain the names, addresses and approximate dates of treatment for all medical care providers, VA and non-VA, that treated the veteran for his claimed heart disease. After the veteran has signed the appropriate releases, those records not already associated with the claims folder, should be obtained and associated with the claims folder. All attempts to procure records should be documented in the file. If the AOJ cannot obtain records identified by the veteran, a notation to that effect should be inserted in the file. The Veteran is to be notified of unsuccessful efforts in this regard, in order to allow him the opportunity to obtain and submit those records for VA review. The Veteran and his attorney should also be provided with a VCAA letter again informing that of what is required to substantiate this service connection claim, including the question of entitlement on a secondary basis under 38 C.F.R. § 3.310. 2. The Veteran should thereafter be scheduled for a VA examination in order to determine the nature and etiology of any heart disease. The examiner should review the contents of the claims file, and obtain relevant history from the Veteran. All indicated tests and studies should be undertaken. Upon examination and review of the entire claims folder, the examiner should provide a clear opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's current heart disorder was caused by or is proximately due to his service-connected diabetes mellitus. If a causal relationship is not found, the examiner is asked to opine as to whether the Veteran's heart disorder has increased in severity due to his service-connected diabetes mellitus. A discussion of the complete rationale for any opinion expressed should be included in the examination report. If the examiner is unable to provide any requested opinion without resorting to speculation, the examiner must provide an explanation for the basis of that determination--for example, whether the examiner lacks the expertise to render such an opinion, or whether some additional testing or information is needed, and possibly available, that would permit an opinion. Any additional evidentiary development deemed necessary should be undertaken. The examiner must provide a complete rationale for each opinion given. It is requested that the examiner discuss the available medical evidence and reconcile any conflicting evidence. 3. The AOJ must ensure that all requested actions have been accomplished 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 (1998). 4. Thereafter, the AOJ should readjudicate the Veteran's claim on the basis of all evidence of record and all applicable laws and regulations. If any determination remains unfavorable to the Veteran, both he and his attorney should be furnished a SSOC, which includes a summary of additional evidence submitted, and any additional applicable laws and regulations. The SSOC must provide reasons and bases for the decision reached. Thereafter, the Veteran and his attorney should be given the 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 the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs