Citation Nr: 1341471 Decision Date: 12/16/13 Archive Date: 12/31/13 DOCKET NO. 09-46 947 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for skin disorders. 2. Entitlement to service connection for type II diabetes mellitus. 3. Entitlement to service connection for peripheral neuropathy of the upper extremities. 4. Entitlement to service connection for peripheral neuropathy of the lower extremities. 5. Entitlement to service connection for hypertension. 6. Entitlement to service connection for heart disease. 7. Entitlement to service connection for an eye disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD K. J. Kunz, Counsel INTRODUCTION The Veteran served on active duty from October 1962 to May 1967. This appeal comes before the Board of Veterans' Appeals (Board) from a March 2009 rating decision by the Waco, Texas Regional Office (RO) of the United States Department of Veterans Affairs (VA). In that decision, the RO denied service connection for skin disorders, diabetes, peripheral neuropathy of the upper and lower extremities, hypertension, heart disease, and an eye disorder. In June 2011, the Veteran had a Travel Board hearing before the undersigned Acting Veterans Law Judge (Acting VLJ). A transcript of that hearing is of record. In December 2011, and again in August 2013, the Board remanded the claim for the development of additional evidence. The Board is satisfied that there has been substantial compliance with the remand directives. The Board will proceed with review. See Stegall v. West, 11 Vet. App. 268 (1998). The Veteran's claims file is in electronic form. The Board has reviewed both his file in the Veterans Benefits Management System (VBMS) and his file in the Virtual VA system, to ensure a total review of the evidence. Any future consideration of this Veteran's case should take into consideration the existence of this electronic record. In an October 2012 statement, the Veteran appeared to raise compensation issues regarding hearing loss. The RO previously granted service connection for left ear hearing loss and assigned a 0 percent disability rating, and denied service connection for right ear hearing loss. In the October 2012 statement the Veteran also appeared to raise claims of service connection for disabilities of the left and right knees. Thus, the issue of reopening of a previously denied claim for service connection for right ear hearing loss, the issues of service connection for left and right knee disabilities, and the issue of an increased disability rating for left ear hearing loss, each have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over those issues, and they are referred to the AOJ for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issues of service connection for skin disorders and hypertension are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. The Veteran went ashore in Vietnam during his Naval service; he presumably was exposed to an herbicide agent. 2. The Veteran has type II diabetes mellitus. 3. Service-connected diabetes caused peripheral neuropathy of the upper extremities. 4. Service-connected diabetes caused peripheral neuropathy of the lower extremities. 5. The Veteran has coronary artery disease. 6. The Veteran did not have any eye disorder during service. 7. The Veteran has not been found to have diabetic retinopathy. 8. Post-service worsening of the Veteran's visual acuity is not related to or aggravated by his diabetes. CONCLUSIONS OF LAW 1. The Veteran's diabetes is presumed to have developed as a result of his herbicide exposure in service. 38 U.S.C.A. §§ 1110, 1112, 1116, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). 2. Peripheral neuropathy of the upper extremities is proximately due to or the result of service-connected diabetes. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2013). 3. Peripheral neuropathy of the lower extremities is proximately due to or the result of service-connected diabetes. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2013). 4. The Veteran's coronary artery disease is presumed to have developed as a result of his herbicide exposure in service. 38 U.S.C.A. §§ 1110, 1112, 1116, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (20130. 5. No eye disorder was incurred or aggravated in service, or is proximately due to, the result of, or aggravated by any service-connected disability. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310, 4.9 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist a claimant in the development of a claim for VA benefits. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). The notice requirements of the VCAA require VA to notify the appellant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has stated that the requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). Insufficiency in the timing or content of VCAA notice is harmless, however, if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). Also, in Bryant v. Shinseki, 23 Vet. App. 488, 493-94 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that that the VLJ who conducts a Board hearing fulfill duties to (1) fully explain the issues and (2) suggest the submission of evidence that may have been overlooked. The Board provided the appellant with VCAA notice in letters issued in August 2005, October 2005, October 2006, and December 2009. In those letters the RO addressed the information and evidence necessary to substantiate claims for service connection. The RO informed the appellant how VA assigns disability ratings and effective dates. The letters also addressed who was to provide the evidence. In the June 2011 Travel Board hearing, the undersigned Acting VLJ fully explained the issues and suggested the submission of evidence that may have been overlooked. The appellant has not asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any prejudice in the conduct of the Board hearing. The Board therefore finds that, consistent with Bryant, the VLJ who conducted the hearing complied with the duties set forth in 38 C.F.R. § 3.103(c)(2), and that any error provided in notice during the appellant's hearing constitutes harmless error. The Veterans claims file (including records in VBMS and Virtual VA) contains service treatment records, records of post-service treatment and examinations, a transcript of the June 2011 Board hearing, and the Veteran's disability claims file from the United States Social Security Administration (SSA). The Veteran has not had a VA medical examination that addressed his claim for service connection for an eye disorder, which he describes as diabetic retinopathy. VA is obliged to provide an examination or obtain a medical opinion in a claim for service connection when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). As explained below, the record does not contain competent evidence that the Veteran has diabetic retinopathy. In the absence of competent evidence of current diabetic retinopathy, VA does not have a duty to provide a medical examination addressing the claim for service connection for diabetic neuropathy. In the December 2011 remand, the Board instructed the RO to obtain more recent VA treatment records, to provide a VA examination addressing the skin disorder service connection claim, and to seek service department records relevant to the Veteran's account of service near and in Vietnam. In the August 2013 remand, the Board instructed the RO to obtain the Veteran's SSA disability claims file. When the Veteran's VA claims file was returned to the Board, it contained more recent VA treatment records, the report of VA examinations addressing the Veteran's skin disorder, service department records regarding the vessels upon which the Veteran served, and the Veteran's SSA disability claims file. With respect to the claims that the Board is deciding at this time, the Board is satisfied that the compliance with the remand directives has been sufficient to protect the Veteran's interests, such that the Board may proceed with review on those claims. See Stegall v. West, 11 Vet. App. 268 (1998). With respect to the claims that the Board is deciding at this time, the Veteran was notified and aware of the evidence needed to substantiate the claims, as well as the avenues through which he might obtain such evidence, and the allocation of responsibilities between the appellant and VA in obtaining such evidence. The appellant has actively participated in the claims process by providing evidence and argument. Thus, he was provided with a meaningful opportunity to participate in the claims process, and he has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication nor to have caused injury to the Veteran's interests. See Pelegrini, 18 Vet. App. at 121. Therefore, any such error is harmless, and does not prohibit consideration of those claims on their merits. See Conway, 353 F.3d at 1374, Dingess, 19 Vet. App. 473; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Diabetes Mellitus The Veteran contends that his type II diabetes mellitus is attributable to exposure during service to herbicides such as Agent Orange. He asserts that during service aboard vessels in the waters of Vietnam he set foot on land in Vietnam. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection also may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including diabetes mellitus, may be established based upon a legal presumption by showing that it manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. The Court has explained that, in general, service connection requires (1) evidence of a current disability; (2) medical evidence, or in certain circumstances lay evidence, of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Under 38 C.F.R. § 3.303(b), if a chronic disease or injury is shown in service, subsequent manifestations of the same chronic disease or injury at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. The provisions of 38 C.F.R. § 3.303(b) have been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Under certain circumstances, service connection for specific diseases, including type II diabetes mellitus, may be presumed if a veteran was exposed during service to certain herbicides, including Agent Orange. 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307, 3.309(e). If a veteran was exposed to Agent Orange or another herbicide agent, service connection for diabetes mellitus will be presumed if that disease becomes manifest to a degree of 10 percent disabling at any time after service. 38 C.F.R. §§ 3.307(a)(6)(ii), 3.309(e). A veteran who served on active duty in the Republic of Vietnam during the period from January 9, 1962 to May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during service. 38 C.F.R. § 3.307(a)(6)(iii). Service in the Republic of Vietnam includes service in the waters off shore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a)(6)(iii). There is no presumption for exposure to herbicides for a veteran who served aboard ship off the shores of the Republic of Vietnam. In Haas v. Peake, 525 F.3d 1168, 1187-1190 (Fed. Cir. 2008), the Federal Circuit confirmed VA's interpretation of 38 C.F.R. § 3.307(a)(6)(iii) as requiring a servicemember's presence at some point on the landmass or inland waters of Vietnam in order to benefit from the regulation's presumption. Thus, a veteran must actually set foot within the land borders of Vietnam, to include the contiguous waterways, in order to be entitled to the statutory presumptions for disabilities claimed as a result of exposure to herbicides. See Haas, supra; see also VAOPGCPREC 27-97. If a veteran did not serve in the Republic of Vietnam during the Vietnam era, actual exposure to herbicides must be verified through appropriate service department or other sources in order for the presumption of service connection for a herbicide-related diseased under 38 C.F.R. § 3.309(e) to be applicable. Exposure to herbicides is not presumed in such instances. However, once exposure to herbicides has been established by the evidence of record, the presumption of service connection found in 38 C.F.R. § 3.309(e) for herbicide-related diseases is applicable. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Veteran has indicated that he was diagnosed with type II diabetes mellitus more than a year after his separation from service. He contends that his diabetes was caused by his exposure to Agent Orange in Vietnam. He states that he set foot on shore in Vietnam while serving on the USS Chanticleer, a submarine rescue ship, and the USS Catfish, a submarine. The Veteran's service records show that he served on the Chanticleer during parts of 1963 and 1964, and on the Catfish from 1964 to 1966. Service department histories record that the Chanticleer visited the port of Saigon, Vietnam, during a Western Pacific tour in late 1962 through early 1963. In early 1964 the Chanticleer had another Western Pacific tour. The Catfish was deployed in the Western Pacific from January to July 1964, and again in the later part of 1965. The Catfish was in the waters of Vietnam during two periods between July and October 1965. The Veteran was awarded a Vietnam Service Medal based on his service on the Catfish in those parts of 1965. On VA examination in February 2006, the Veteran reported that during service he was a quartermaster on a submarine, and that he also spent ten and a half weeks in Vietnam with the US Marine Corps. In an October 2006 telephone conversation between the Veteran and an RO employee, the Veteran reportedly stated that during service he was on shore in Vietnam when the submarine he served on was wrecked, and he had to swim to shore. In the June 2011 Travel Board hearing, the Veteran indicated that he was on land in Vietnam during his service on the Chanticleer and his service on the Catfish. He stated that when he was on the Chanticleer he was assigned to swim out and rescue pilots who were shot down. He indicated that in performing those duties he swam close to shore and went on to land fifty to a hundred times. He related that when he was on the Catfish he did the same thing, swimming from the submarine to the shore and back again. He also stated that he was the coxswain in a boat that took Marines from a ship to the shore. He stated that in those duties he sometimes stepped ashore. He indicated that, during his duties on the Catfish, in approximately August of 1965, the boat to shore that he was in was hit by a mortar, and he dove off the boat and swam to shore. He reported that on that occasion he spent ten days on land in Vietnam with Marines who were headed to Cambodia. He stated during those ten days on land he observed and came into contact with defoliant that was being sprayed. The Veteran reports that he set foot on land in Vietnam during his service on the Chanticleer and the Catfish. His account is consistent with Naval records regarding the locations of those vessels during the Veteran's service on them. Records from the vessels do not contain sufficient detail to indicate which crewmembers went ashore. The Veteran's account that he went ashore in the course of transporting Marines to shore is plausible, however, in the context of his duties aboard vessels located in the waters off of Vietnam. Resolving reasonable doubt in the Veteran's favor, the Board accepts that the Veteran went on land in Vietnam during service. In accordance with §38 C.F.R. § 3.307(a)(6)(iii), the Board presumes that while the Veteran was on land in Vietnam he was exposed to an herbicide agent. VA medical records reflect that the Veteran has type II diabetes mellitus. As he was exposed to an herbicide agent in service and he has type II diabetes mellitus, the Board presumes that his diabetes is service connected. Peripheral Neuropathy The Veteran contends that he has peripheral neuropathy in both upper extremities and both lower extremities as a result of his diabetes. In this decision, the Board has granted service connection for the Veteran's diabetes. Service connection may be granted for a disability which is proximately due to or the result of a service-connected disease or injury, or for aggravation of a non-service-connected disability by a service-connected disability. 38 C.F.R. § 3.310. VA medical records, including diabetic clinic notes from February 2006, show that the Veteran has peripheral neuropathy in both hands. VA medical records, including primary treatment notes from March 2010, show that the Veteran has peripheral neuropathy from diabetes in both feet. Medical evidence indicates that peripheral neuropathy in the Veteran's upper extremities and lower extremities is due to his service-connected diabetes. The Board therefore grants service connection for that neuropathy. Heart Disease VA medical records, including treatment records from 2004 forward, show that the Veteran has valvular heart disease and coronary artery disease. The Veteran is seeking service connection for heart disease as related to his herbicide exposure in service. Ischemic heart disease, including coronary artery disease, is among the diseases listed under 38 C.F.R. § 3.309(e) for which service connection is presumed in a veteran who was exposed to herbicides during service. As the Veteran had presumed exposure to herbicides when he went ashore in Vietnam during service, and he has coronary artery disease, the Board presumes that the coronary artery disease is service connected. Eye Disorder The Veteran essentially contends that he has a bilateral eye disorder, described as diabetic retinopathy, as a result of his diabetes. He states that his vision has worsened over time, such that he has needed stronger prescriptions for corrective lenses. He asserts that this is due to diabetic retinopathy. Refractive error of the eye is not a disease or injury for purposes of service connection and VA disability compensation. 38 C.F.R. §§ 3.303(c), 4.9. Nonetheless, an eye disorder caused or aggravated by a service-connected disability could be service-connected under 38 C.F.R. § 3.310. The Veteran does not contend that he had any eye disorder during service, nor that his visual acuity decreased during service. On examinations throughout his service his vision was measured as 20/20 bilaterally. He did not receive treatment during service for any eye problems. Post-service medical records reflect that after service the Veteran began wearing glasses to address refractive error, and that his prescription has changed over time. The Veteran receives VA treatment for his diabetes. Treatment records do not contain any indication that his diabetes has produced effects on his eyes or vision. In treatment notes dated in March 2006 and August 2008, clinicians found that he did not have diabetic retinopathy. The Veteran states that he has diabetic retinopathy. The Veteran is competent to report increased difficulty seeing and a history of stronger eyeglass prescriptions over time. As a person without medical training, however, he is not competent provide a diagnosis such as diabetic retinopathy. VA clinicians who are competent to determine whether diabetic retinopathy is present have specifically found that the Veteran does not have diabetic retinopathy. There is no medical evidence supporting a connection between the Veteran's diabetes and his diminishing visual acuity. The preponderance of the evidence thus indicates that the Veteran does not currently have diabetic retinopathy or other eye disorder related to or aggravated by his diabetes, or as the result of a disease or injury incurred in service. The Board therefore denies service connection for an eye disorder. ORDER Entitlement to service connection for type II diabetes mellitus is granted. Entitlement to service connection for peripheral neuropathy of the upper extremities is granted. Entitlement to service connection for peripheral neuropathy of the lower extremities is granted. Entitlement to service connection for coronary artery disease is granted. Entitlement to service connection for an eye disorder is denied. REMAND The Board is remanding, for the development of additional evidence, the issues of service connection for skin disorders and hypertension. The Veteran essentially contends that he has skin disorders that began during service or as a result of herbicide exposure during service. He has sought service connection for skin disorders either on a direct basis, as incurred in service, or through presumed service connection, as a result of herbicide exposure in service. The skin disorders for which service connection may be presumed based on herbicide exposure are porphyria cutanea tarda, chloracne, and other acneform disease consistent with chloracne. Medical records from during and after service do not show that the Veteran has had any of those skin disorders. On medical examinations in 2006 and 2012 the skin disorders diagnosed were actinic keratosis, seborrheic keratosis, dermatitis, and cherry angiomas. As the Veteran does not currently have any of the skin disorders that are subject to presumptive service connection based on herbicide exposure, no additional evidence is needed regarding service connection on a presumptive basis. Additional evidence is needed regarding his claim that current skin disorders were incurred in service. No skin disorder was noted when the Veteran was examined in September 1962 for entrance into service. The Veteran's service treatment records reflect treatment for skin disorders during service. He was noted to have a mole on his left elbow in July 1963. Clinicians removed warts from his right forearm in September 1964 and from his right forehead in September 1964, January 1965, and August 1965. Also in August 1965, a clinician incised and drained an abscess, or boil, on his left forearm. Reports of examinations in May 1966 and October 1966 contain notations of scars on the right forearm, left elbow, and right forehead. In a December 2011 remand, the Board noted the treatment record notations of skin disorders. The Board instructed that the Veteran receive a VA skin examination, with review of the file, and opinion as to the likelihood that current skin disorders are related to disorders noted during service. The Veteran had a VA examination of his skin in February 2012, but the examiner did not review the Veteran's claims file. He had another VA examination of his skin in May 2012. The examiner reported having reviewed the Veteran's claims file. The examiner provided the opinion that it is less likely than not that the Veteran's skin disorders are related to his service. The examiner explained that the Veteran's claims file is silent for skin problems or complaints or dermatology evaluations during service. The May 2012 VA examiner's finding that the claims file does not show any skin problems during service is inconsistent with the service treatment records that show warts, a mole, a boil, and scars. The examiner's opinion fails to address the relevant evidence of skin disorders during service. In order to obtain an opinion that adequately addresses the relevant facts, the Board will remand the skin disorder service connection claim for an appropriate clinician to review the service treatment records and the recent examination reports, and to provide and explain an opinion as to the likelihood that current skin disorders are related to skin disorders treated in service. Medical records show that the Veteran has hypertension. The Veteran has sought service connection for his hypertension as a result of herbicide exposure, or as secondary to his diabetes. He has not contended, and medical records do not contain evidence, that his hypertension became manifest during service or the year following separation from service. While ischemic heart disease is among the diseases for which service connection may be presumed in veterans exposed to herbicides, hypertension is not. See 38 C.F.R. § 3.309(e) Note 3 (2013). The Veteran has reported that his diabetes and hypertension were each diagnosed in 1976. The claims file does not contain any medical opinion as to the likelihood that the Veteran's hypertension is secondary to his diabetes. The Board will remand the issue for a VA medical examination with review of the file and opinion addressing that question. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). Expedited handling is requested.) 1. Provide the Veteran's claims file, including records in the Veterans Benefits Management System (VBMS) and in the Virtual VA system, to a VA clinician to review. Ask the reviewer to consider the Veteran's skin disorders noted during service, described as warts, moles, boils, and scars, and his post-service skin disorders, described on examinations as actinic keratosis, seborrheic keratosis, dermatitis, and cherry angiomas. Ask the reviewer to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater chance) that any current skin disorder is a continuation of, or otherwise causally related to, skin disorders that manifested in service. Ask the reviewer to explain the conclusions reached. 2. Schedule the Veteran for a VA medical examination to address the likely etiology of his hypertension. Provide the examiner the Veteran's claims file, including records in VBMS and in Virtual VA, for review. Ask the examiner to review the Veteran's files and examine the Veteran. Ask the examiner to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater chance) that the Veteran's hypertension is proximately due to or the result of his service-connected type II diabetes mellitus. Ask the examiner to explain the conclusions reached. 3. Thereafter review the expanded record and reconsider the remanded claims. If any remanded claim remains denied, issue a supplemental statement of the case and afford the Veteran and his representative an opportunity to respond. Thereafter, return the case to the Board for appellate review if otherwise in order. The Board intimates no opinion as to the ultimate outcome of the matters that the Board has remanded. The Veteran has the right to submit additional evidence and argument on those matters. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ T. D. Jones Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs