Citation Nr: 1335900 Decision Date: 11/05/13 Archive Date: 11/13/13 DOCKET NO. 08-28 004 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus, type II, and herbicide exposure. 2. Entitlement to service connection for a kidney disorder, to include as secondary to service-connected diabetes mellitus, type II. 3. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected diabetes mellitus, type II. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD J. Smith, Counsel INTRODUCTION The Veteran served on active duty from August 1964 to August 1966. The Veteran's claim comes before the Board of Veterans' Appeals (Board) on appeal from an August 2007 rating decision of the Department of Veterans Affairs' (VA) Regional Office (RO) in St. Petersburg, Florida. In April 2010, the Veteran and his spouse testified during a hearing before a retired Veterans Law Judge at the RO; a transcript of that hearing is of record. In September 2010, the issues involving hypertension and a kidney disorder were denied by the Board, and the issue involving erectile dysfunction was remanded for further development. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In a February 2012 Memorandum Decision, the Court set aside the September 2010 Board decision and remanded the matter back to the Board for development consistent with the Memorandum Decision. As noted, the Veterans Law Judge who conducted the April 2010 hearing is no longer employed at the Board. The law requires that the Veterans Law Judge that conducted the Board hearing shall participate in making the final determination of the claim. 38 U.S.C.A. § 7107(c) (West 2002); 38 C.F.R. § 20.707 (2012). Thus, the Veteran was given the opportunity to request another Board hearing. In June 2012, the Veteran indicated that he did not wish to appear at another hearing and requested that his appeal be considered based on the evidence of record. In January 2013, the Board remanded the appeal for development consistent with the February 2012 Memorandum Decision. The claim for erectile dysfunction was remanded as inextricably intertwined with the claim for hypertension. In accordance with argument presented by the Veteran's representative in December 2012, the Board has recharacterized the claim for hypertension as also involving herbicide exposure. The Board has considered documentation included in the Virtual VA system in reaching the determination below. At present, the system contains a March 2013 VA examination report that is not physically in the file, but that was considered by the RO in the last supplemental statement of the case. The issues of entitlement to service connection for hypertension and erectile dysfunction 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. A kidney disorder was not manifest during service or within one year of separation. A kidney disorder is not attributable to service. 2. A kidney disorder is unrelated (based on causation or aggravation) to a service-connected disease or injury. CONCLUSIONS OF LAW 1. The criteria for service connection for a kidney disorder have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & 2012); 38 C.F.R. §§3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). 2. A kidney disorder is not proximately due to or the result of a service-connected disease or injury. 38 C.F.R. 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance Under applicable law, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Board finds that the content requirements of a duty to assist notice have been fully satisfied. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). A letter from the RO dated in November 2006 provided the Veteran with an explanation of the type of evidence necessary to substantiate his claim, to include on a secondary basis, as well as an explanation of what evidence was to be provided by him and what evidence the VA would attempt to obtain on his behalf. That letter additionally provided him with information concerning the evaluation and effective date that could be assigned should service connection be granted, pursuant to Dingess v. Nicholson, 19 Vet. App. 473 (2006). VA has no outstanding duty to inform the Veteran that any additional information or evidence is needed. VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Here, the Board finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issue has been obtained. The Veteran's service treatment records and post service treatment records have been obtained. He has been afforded VA examinations for the claim decided herein. The Veteran was also afforded an opportunity to present testimony at a hearing before the Board. During the hearing, the Veterans Law Judge who conducted the hearing clarified the issue on appeal, explained the concept of service connection, identified an evidentiary deficit, and suggested the submission of additional evidence to support the Veteran's claim. The VLJ left the record open for a 60-day period following the hearing to allow for the submission of such additional evidence. The actions of the VLJ supplement the VCAA and comply with any related duties owed during a hearing. To the extent the Court, citing Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010), raised the issue of whether the Veterans Law Judge properly suggested the submission of particular evidence at the hearing, namely, McIver Clinic medical records, any defect has been since cured. The Veteran subsequently submitted the McIver Clinic records, ranging in date from 1979 to 2012. For all of these reasons, the Board does not have notice of any additional relevant evidence which is available but has not been obtained. The Board is further satisfied that the RO has substantially complied with its January 2013 remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board engagement letter requesting a medical opinion is required). As directed by the Board, the AOJ afforded the Veteran the opportunity to submit additional pertinent evidence, and afforded him a VA examination for the claim on appeal. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). For the foregoing reasons, the Board concludes that all reasonable efforts were made by the VA to obtain evidence necessary to substantiate the Veteran's claim. Therefore, no further assistance to the Veteran with the development of evidence is required. Analysis Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be warranted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In relevant part, 38 U.S.C.A. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a disorder when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted.") The Veteran in this case has been diagnosed with chronic kidney disease with kidney failure documented, for example, on VA examination in March 2013. Thus, the question is whether his current disability is related to active service or events therein. See 38 C.F.R. § 3.303. As for the in-service incurrence of the condition, initially, the Board notes that the Veteran does not claim that his kidney disability is due to combat. Therefore, the combat provisions of 38 U.S.C.A. § 1154 (West 2002) are not applicable. A June 1966 service medical record documented blood in the urine. As recounted by the March 2013 VA examiner, a June 16, 1966 urinalysis report found red blood cells too numerous to count , 20 to 25 white blood cells, dip stick with moderate blood, and no protein. A June 17, 1966 record shows the Veteran reported a few drops of blood at the end of voiding, and the urinalysis from the previous day was noted. On separation from service, the Veteran's genitourinary system was normal. No hematuria or other genitourinary-related condition was found. A urinalysis was normal. Post service, the Veteran underwent a VA examination in November 1970. The Veteran was noted as having painless hematuria from his own history. The cause was undetermined and no current symptoms or diagnosis were noted upon examination. Private treatment records from as early as the 1980's reflect complaints regarding the kidney and kidney stones. See Dr. I.H., M.D. treatment record, February 1983. He was eventually diagnosed with chronic renal insufficiency, attributed to nephrolithiasis. See Dr. I.H., M.D. treatment record, July 2001. In an April 2006 private medical record from Dr. H., the Veteran was diagnosed with chronic kidney disease secondary to hypertensive nephrosclerosis. The Veteran underwent a VA examination in February 2007. The examiner reviewed the claims file and noted the Veteran's medical history relating to his kidney complaints. The examiner, however, did not discuss the service treatment records in any way. The Veteran was diagnosed with chronic kidney disease. The examiner concluded by offering an opinion on the issue of secondary service connection. In October 2012, the Veteran submitted a private medical report of Dr. H.. Dr. H. indicated in the report that he had served as the Veteran's physician since February of 1983. Prior to that, the Veteran had been treated by another physician who retired and transferred all of the Veteran's records to Dr. H. Dr. H. indicated that in preparing the report, these records had been carefully reviewed. Dr. H. noted that in 1966 the Veteran was found to have gross hematuria which was otherwise asymptomatic. There was no definite explanation for the hematuria, but it was Dr. H.'s strong suspicion that it was due to nephrolithiasis ("the diseased condition associated with the presence of renal calculi," Dorland's Illustrated Medical Dictionary at 1230 (30th ed. 2003). The Veteran was later found to have sarcoidosis with lung, liver, and probably kidney involvement. Dr. H. stated that the sarcoidosis probably preceded his induction into service, and very likely contributed to his nephrolithiasis and possible nephrocalcinosis. Those problems subsequently led to advanced chronic kidney disease and hypertension due to renal parenchymal disease. Dr. H. concluded that he strongly believed that the Veteran's chronic kidney disease and hypertension are service connected illnesses. In January 2013, the matter was returned to the Board. The Board remanded the appeal for development in compliance with the Court's February 2012 Memorandum Decision. In March 2013, an examination was conducted. The examiner reviewed the claims file, including service treatment records. An extensive medical history was recounted in detail. With regard to the service treatment records, the examiner noted that on entry into service, a chest x-ray noted possible Boeck's sarcoid, with a plan to refer to a private doctor and re-evaluate 6 months. The accompanying Report of Medical History was silent for respiratory symptoms. On examination in April 1964, there was no significant history noted other than venereal disease, and the Veteran's chest was normal. In July 1965 the right testis had been painful for 24 hours, and the impression was possible epididymitis. The plan was urinalysis and scrotal support. A July 1965 urinalysis report found too numerous to count white blood cells, and no red blood cells. The Veteran was seen later in July 1965 for follow up. The epididymis was enlarged and the impression was acute epididymitis. A urine culture was sent and the Veteran was treated with Tetracycline. The urinalysis revealed colonies of some type of organism but the examiner was unable to determine the type. In July 1966, the Veteran presented with a lesion on penis, which was felt to be due to syphilis. He was treated with penicillin. In February 1966, the lesion was healing well. Later that month, the sores returned. In March 1966 the lesions were healing slowly, and the Veteran was treated with Tetracycline. In May 1966, there were again lesions on penis, but it was unclear if these were new lesions or the non-healing of the previous lesions. The impression was chancroid. A June 16, 166 urinalysis report found too numerous to count red blood cells, 20 to 25 white blood cells, a dip stick reading with moderate blood, and no protein. He was seen the next day and reported a few drops of blood at end of voiding. On Jun 18, 1966 there were a few vesiculated lesions on penis, with an exposure three days prior. The impression was herpes and he was treated with Tetracycline. In July 1966, there was only one lesion which appeared to be chancroid. The August 1966 separation exam was silent for hematuria or any other genitourinary condition. An August 13, 1966 urinalysis was negative. Based on these service treatment records, and an equally thorough review of the post-service medical record, the examiner determined that the Veterans renal failure and nephrolithiasis are less likely as not due to active military service. As rationale, the examiner noted that the service treatment records, and medical record from within one year of active duty, do not document renal failure or nephrolithiasis. While the Veteran had an isolated episode of hematuria in service, the examiner noted there are many causes of hematuria, including infection in the upper or lower genitourinary tract, a tumor in any of the genitourinary organs, trauma, prostate conditions, or nephrolithiasis. The examiner noted that generally nephrolithiasis presents with flank pain and microscopic hematuria, as opposed to painless gross hematuria like the Veteran had. Based on the above, the examiner felt it would be speculative to opine on the cause of the isolated episode of hematuria in 1966. The examiner noted that in his October 2012 report, Dr. H. did not give a rationale for his opinion that the in-service hematuria was due to nephrolithiasis. As indicated above, the medical evidence of record contains conflicting evidence on the question of whether the Veteran's kidney disorder is related to service. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). A medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board finds here that the opinion of the March 2013 VA examiner outweighs that of the October 2012 report of Dr. H. There is no indication that Dr. H. reviewed the Veteran's claims file. Rather, Dr. H. indicated that he had reviewed his own private medical records, and those of the Veteran's former physician, whose practice he had taken over. The Board does not discount the opinion solely on this basis, but finds this fact significant because the Veteran's service treatment records were not reviewed by Dr. H. It is thus unclear how Dr. H. arrived at the "strong suspicion" that the Veteran's hematuria in 1966 was due to nephrolithiasis. Dr. H.'s conclusion in this regard was unsupported by any rationale. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.") On this point, the Board is further persuaded by the March 2013 examiner's explanation that hematuria can be caused by a variety of factors, and that based on a thorough review of the service treatment records, the symptoms normally accompanying nephrolithiasis were not present in 1966. The Board finds the probative value of the October 2012 report is further diminished to the extent that Dr. H. appears to attribute a preexisting condition of sarcoidosis to the Veteran's in-service nephrolithiasis and subsequent chronic kidney disease. The Veteran was noted on a pre-induction examination report as having possible Boeck's sarcoidosis. However, as found by the Board in September 2010, to the extent that sarcoidosis possibly pre-existed service, there is no indication that it was aggravated during service. The only indication that the hematuria could possibly be a symptom of this disease is the opinion of Dr. H., who did not actually review the service treatment records. Moreover, the Veteran does not assert his current kidney symptoms are related to a pre-existing diagnosis of sarcoidosis. For all of these reasons, the Board finds the October 2012 report of Dr. H. to be of low probative value. By contrast, the Board finds the March 2013 VA examination report adequate for the purposes of adjudication. See Stefl, 21 Vet. App. at 123. The examiner founded her opinion on an extensive examination of the claims file and of the Veteran, with reference to past and current diagnostic reports. She accepted and discussed the in-service hematuria in rendering her opinion, and explained the reasons for her conclusion. The Board finds the preponderance of the evidence is against the claim for direct service connection. The Board further notes that, chronic disabilities, such as calculi of the kidney, cardiovascular-renal disease, and nephritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. However, as there is no evidence documenting these diseases from within one year of the Veteran's discharge from active duty in August 1966, the Board finds that presumptive service connection is not warranted on this basis. Furthermore, kidney disease was not noted or diagnosed during service. See 38 C.F.R. §3.303(b). The Veteran alternatively asserts his kidney disease is secondary to his service-connected diabetes mellitus, type II. In order to prevail under this theory of entitlement there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). In addition, the regulations provide that service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (2012). Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. The Board notes that 38 C.F.R. § 3.310 was amended effective October 10, 2006. Under the revised § 3.310(b) (the existing provision at 38 C.F.R. § 3.310(b) was moved to sub-section (c)), any increase in severity of a nonservice-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service-connected. In reaching this determination as to aggravation of a nonservice-connected disability, consideration is required as to what the competent evidence establishes as the baseline level of severity of the nonservice-connected disease or injury (prior to the onset of aggravation by service-connected condition), in comparison to the medical evidence establishing the current level of severity of the nonservice- connected disease or injury. These findings as to baseline and current levels of severity are to be based upon application of the corresponding criteria under the Schedule for Rating Disabilities (38 C.F.R. part 4) for evaluating that particular nonservice- connected disorder. See 71 Fed. Reg. 52,744-47 (Sept. 7, 2006). Here, there is no dispute that the Veteran is service-connected for diabetes mellitus and carries a current diagnosis of kidney disease. However, the evidence is not in equipoise as to whether the Veteran's service-connected disability caused or aggravated his kidney disease. The only opinions in this regard are those of the February 2007 and March 2013 VA examiners. The February 2007 VA examiner found that the Veteran's chronic kidney disease was not caused by or a result of diabetes because the onset of kidney stones and resultant decreased kidney function was in the 1980s, with no worsening of kidney function since the diabetes diagnosis. There was also no evidence to support aggravation because the Veteran's creatine had actually slightly improved since the diagnosis of diabetes. The March 2013 examiner found that the kidney disease was not caused by diabetes. As rationale, the examiner determined that the onset of the Veteran's diabetes was 2004, and that his renal failure and nephrolithiasis clearly had an onset prior to 2004. The examiner additionally found that the kidney disease was not aggravated by the Veteran's service-connected diabetes mellitus, type II. As rationale, the examiner found no objective evidence of worsening of kidney failure or nephrolithiasis beyond the natural progression of the disease. Additionally, the Veteran did not require dialysis until after his nephrectomy (creatinine was stable until then). His nephrolithiasis has been quiescent for the past 8-9 years. There is no evidence to the contrary of these opinions. To the extent the Court noted in its analysis of the kidney claim that the February 2007 VA examination report "contains only data and conclusions without any 'reasoned medical explanation connecting the two,'" the Board notes that the February 2007 examiner did provide a rationale for the conclusions reached. The examiner rendered negative findings on secondary service connection based on the facts that the Veteran's kidney disease began in the 1980s, his kidney function had not worsened since the diabetes diagnosis, and his creatine had slightly improved since the diabetes diagnosis. Nevertheless, the record additionally contains the negative opinion of the March 2013 VA examiner. The Board finds the report fully adequate for the purposes of adjudication as discussed above. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). To the extent the record suggests that the Veteran's kidney disorder was caused by his hypertension, as indicated by the April 2006 record showing chronic kidney disease secondary to hypertensive nephroclerosis, the record shows that the Veteran's kidney disorder developed prior to his hypertension. As outlined by the March 2013 VA examiner, for example, the Veteran first began experiencing kidney stone disease in February 1983. There was no treatment or diagnosis of hypertension prior to that point. Borderline blood pressure was initially noted in November 1983, and hypertension was not actually diagnosed until December 1984. As such, secondary service connection is not possible on this basis, and the Board may proceed with adjudication of the kidney disorder claim, while remanding the hypertension claim. In the absence of any competent evidence to the contrary, the preponderance of the evidence is against the claim for secondary service connection. In reaching these decisions, the Board notes that the Veteran, on his own behalf, has contended that his kidney disorder is related to military service or diabetes mellitus. Lay statements can be competent as to some matter of diagnosis and etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, n. 4 (Fed. Cir. 2007) ("sometimes the layperson 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.") In this case, the question of whether the Veteran's current kidney disease are related to his in-service hematuria or diabetes mellitus type II appear to be complex medical matters as to which the Veteran's lay statements are not competent. To the extent that the Veteran's statements indicating a nexus between his current disabilities and service are competent, these general assertions are outweighed by the specific, reasoned opinion of the physician who performed the March 2013 VA examination. Here, the medical evidence is far more persuasive and credible than the lay assertions. To the extent the Veteran argues a continuity of symptomatology between the present condition and in-service injury or disease, the United States Court of Appeals for the Federal Circuit recently clarified that the continuity of symptomatology language in § 3.303(b) "restricts itself to chronic diseases" found in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). (holding, "nothing in § 3.303(b) suggests that the regulation would have any effect beyond affording an alternative route for proving service connection for chronic diseases."). In this case, however, the earliest post-service medical evidence is dated from 1970. The earliest documentation of kidney problems is dated from 1983, as outlined by the March 2013 VA examiner. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (holding that evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim.). Here it is concluded that kidney disease was not noted during service and the evidence establishes that there were not characteristic manifestations of the disease process during service. Therefore, the Board finds that continuity of symptomatology regarding the Veteran's kidney disease has not been established. The Board has also considered the fact that VA has conceded he was exposed to herbicides while serving in the Republic of Vietnam during the Vietnam Era. See January 2007 Rating Decision. The Veteran's kidney disorder, however is not among those presumed to be associated with herbicide exposure. See 38 C.F.R. § 3.309(e). He has not otherwise contended that any herbicide exposure caused his kidney disease, and the claims file is devoid of any evidence to support this, including the detailed opinion of the March 2013 VA examiner who extensively reviewed the claims file and opined that the kidney disease is not related to an event of active military service. Finally, the Board has considered the articles submitted by the appellant regarding genitourinary disorders, including hematuria. This evidence, however, does not address the facts that are specific to this Veteran's case. As such, the Board finds that the information reflected in the submitted articles is not probative of the medical questions at issue in this appeal. In short, there is competent evidence that the Veteran has a kidney disorder; however, the more probative and credible evidence establishes that there is no relationship to service or a service-connected disability. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a kidney disorder is denied. REMAND The Board finds that further development is necessary before the claims remaining on appeal can be properly adjudicated. With regard to the claim for hypertension, in a December 2012 brief, the Veteran's representative introduced a new theory of entitlement to service connection. In the December 2012 Brief, the Veteran contended that there is medical literature available that tends to establish that the same mechanism which links the development of diabetes from herbicide exposures, also links the development of hypertension. Herbicide exposure can cause diabetes by inducing insulin resistance, and insulin resistance has also been linked to the development of hypertension. In this case, VA conceded that the Veteran in this case was exposed to herbicides while serving in the Republic of Vietnam during the Vietnam Era. See January 2007 Rating Decision. As such, and although hypertension is not a recognized presumptive disorder of herbicide exposure, in the brief, it was argued that the Veteran's hypertension is related to herbicide exposure on a direct basis. At present, the medical opinions of record do not address this theory of entitlement. The Veteran's representative noted that upon VA examination in March 2013, the examiner had not addressed the question of whether his hypertension could be due to herbicide exposure. The Board finds that such an opinion must be obtained prior to appellate adjudication. With respect to the claim for service connection for erectile dysfunction, the Board notes that pursuant to the September 2010 remand directives, the Veteran was afforded a VA examination addressing the etiology of his claimed erectile dysfunction. In a report of May 2011 VA examination, the examiner opined that it was less likely that the Veteran's erectile dysfunction was due to his diabetes mellitus. However, the examiner noted that the Veteran's long-standing history of hypertension could also be a contributing factor to his erectile dysfunction. Given the development to be undertaken regarding the Veteran's claim for service connection for hypertension, the Board finds that a decision on the Veteran's claim for erectile dysfunction would be premature at this time. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). Accordingly, the case is REMANDED for the following action: 1. The Veteran should be afforded a VA examination to address the nature and likely etiology of his hypertension. The examiner is to be provided access to the claims folder and Virtual VA as needed. Any and all indicated studies deemed necessary by the examiner should be accomplished. The examiner is requested to review all pertinent records associated with the claims file and offer comments and an opinion addressing whether it is at least as likely as not (50 percent probability or greater) that the Veteran suffers from hypertension due to an injury or other event or incident of his period of active service. In so doing, the examiner should specifically opine on whether it is at least as likely as not that the Veteran suffers from hypertension due to in-service herbicide exposure. The examiner is advised that VA has already conceded in-service herbicide exposure. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. The Veteran should be notified that it is his responsibility to report for the examination and to cooperate in the development of the claims. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). 4. After the development requested has been completed, the RO should review the examination report to ensure it is in complete compliance with the directives of this REMAND. If the report is deficient in any manner, the RO must implement corrective procedures at once. 5. The RO should complete any action deemed appropriate in addition to that requested above. Specifically, depending on whether the Veteran's hypertension has been attributed to service by the above-ordered VA examination, the RO should consider whether a more definitive opinion on the issue of secondary service connection for the erectile dysfunction claim is needed. Thereafter, the appellant's claims should be readjudicated. All applicable laws and regulations, and all evidence received should be considered. If any benefit sought remains denied, the appellant should be provided a supplemental statement of the case and given the opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs