Citation Nr: 1328803 Decision Date: 09/09/13 Archive Date: 09/17/13 DOCKET NO. 07-04 587 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for arthritis of the left knee. 2. Entitlement to service connection for arthritis of the lumbar spine. 3. Entitlement to service connection for chronic fatigue syndrome, to include as secondary to service-connected liver cirrhosis and hepatitis C. 4. Entitlement to service connection for prostatitis, to include as secondary to service-connected liver cirrhosis and hepatitis C. 5. Entitlement to service connection for hypertensive vascular disease, to include as secondary to service-connected liver cirrhosis and hepatitis C. 6. Entitlement to service connection for a respiratory disorder, claimed as shortness of breath and obstructive sleep apnea (OSA), to include as secondary to service-connected liver cirrhosis and hepatitis C. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A.J. Turnipseed, Counsel INTRODUCTION The Veteran served on active duty from January 1964 to December 1967. This matter comes before the Board of Veterans' Appeals (Board) from decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In November 2012, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. In December 2012, the Board issued a decision granting service connection for hepatitis, bilateral hearing loss, and cirrhosis of the liver. In that decision, the Board also denied entitlement to an initial compensable rating for service-connected thoracotomy scars. In this regard, the Board notes that supplemental statements of the case (SSOC) issued in July and August 2013 address the issue of entitlement to an increased rating for service-connected thoracotomy scars. However, the Board finds that the increased rating issue was mistakenly included in the July and August 2013 SSOCs because there is no indication that the Veteran appealed the Board's determination as to his increased rating claim following the December 2012 Board decision. Accordingly, that issue is no longer on appeal and will not be discussed in the decision herein. In the December 2012 decision, the Board also remanded the issues of service connection for arthritis of the left knee; arthritis of the lumbar spine; prostatitis; a respiratory disorder; thrombocytopenia; leucopenia; headaches; a psychiatric disorder, to include major depression; hypertensive vascular disease; cholelithiasis; chronic fatigue syndrome; and sciatic neuralgia, also classified as acute and subacute peripheral neuropathy for additional evidentiary development. All requested development has been conducted and the appeal has been returned to the Board for adjudication. However, while this appeal was on remand, the RO granted entitlement to service connection for thrombocytopenia; leucopenia; headaches; dysthymic disorder to be included with PTSD and neurodermatitis; cholelithiasis; and peripheral neuropathy affecting the bilateral lower extremities, which was considered a full grant of the benefit sought with respect to those disabilities. See rating decisions dated May and July 2013. Accordingly, the issues of entitlement to service connection for thrombocytopenia, leucopenia, headaches, a psychiatric disorder, cholelithiasis, and peripheral neuropathy are no longer on appeal and will not be discussed in the decision herein. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). For reasons discussed below, the issues of entitlement to service connection for hypertensive vascular disease, prostatitis, and obstructive sleep apnea are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The most competent, credible, and probative lay and medical evidence of record supports a finding that the Veteran currently has osteoarthritis of the left knee that is related to his active military service. 2. The most competent, credible, and probative lay and medical evidence of record supports a finding that the Veteran currently has degenerative disc disease of the lumbar spine that is related to his active military service. 3. While there is competent medical evidence showing complaints of fatigue, the most competent, credible, and probative lay and medical evidence of record preponderates against a finding that the Veteran has a current diagnosis of chronic fatigue syndrome, as his fatigue has been attributed to his hematologic and encephalopathy conditions. CONCLUSIONS OF LAW 1. Osteoarthritis of the left knee was incurred as a result of active military service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.102, 3.303 (2012). 2. Degenerative disc disease was incurred as a result of active military service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.102, 3.303 (2012). 3. Chronic fatigue syndrome was not incurred in nor aggravated by active service and is not aggravated by, proximately due to, or the result of a service-connected disability. 38 U.S.C.A. §§ 1101, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on the claim for VA benefits. Review of the record reveals that, in September 2005, October 2006, and December 2006, before the initial unfavorable AOJ decisions issued in May 2006 and March 2007, the RO sent the Veteran letters advising him of the evidence and information necessary to substantiate a service connection claim, as well as his and VA's respective responsibilities in obtaining such evidence and information. The 2006 letters also informed him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Review of the record reveals that the Veteran has not been advised of the evidence and information necessary to establish secondary service connection. In Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007), the United States Court of Appeals for the Federal Circuit held that any error by VA in providing the notice required by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)(1) is presumed prejudicial and require reversal unless VA can show that the error did not affect the essential fairness of the adjudication. To do this, VA must show that the purpose of the notice was not frustrated, such as by demonstrating: (1) that any defect was cured by actual knowledge on the part of the claimant, see Vazquez-Flores v. Peake, 24 Vet. App. 94, 97-103 (2010); ("Actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what was necessary to substantiate his or her claim.") (citing Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007)); (2) that a reasonable person could be expected to understand from the notice what was needed; or (3) that a benefit could not have been awarded as a matter of law. Sanders, 487 F.3d at 889. Additionally, consideration also should be given to "whether the post-adjudicatory notice and opportunity to develop the case that is provided during the extensive administrative appellate proceedings leading to the final Board decision and final Agency adjudication of the claim ... served to render any pre-adjudicatory section 5103(a) notice error non-prejudicial." See Vazquez-Flores, supra. In this case, it is not clear if the Veteran and his representative are aware of the evidence needed to establish secondary service connection, i.e., evidence showing that the claimed disabilities are proximately due to, a result of, or aggravated by a service-connected disability. Nevertheless, the Board finds that the essential fairness of the adjudication has not been affected by the notice defect or the Veteran's lack of knowledge in this regard. In making this determination, the Board notes that the evidentiary record contains all pertinent, identified VA and private medical records, which have been obtained and considered by the AOJ and the Board in evaluating this claim. Additionally, the Veteran has been afforded several VA examinations in conjunction with his secondary service connection claims, including in February and March 2013, and it appears that the examiners considered whether the claimed disabilities are secondary to the Veteran's service-connected disabilities. See VA examination reports dated February and March 2013; addendum reports dated June 2013 and undated. There is no allegation or indication that the VA examinations were not adequate for rating purposes; nor is there any indication or allegation that the evidence of record does not sufficiently describe the manifestations of the claimed disabilities. In this context, the Board finds that, even if the Veteran had been properly notified of the evidence and information necessary to establish a secondary service connection claim, the outcome of this case would not have changed. Indeed, as discussed below, unless otherwise indicated, the evidence of record does not reflect that the Veteran's claimed disabilities are secondary to his service-connected disabilities. The Board also notes the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his appeal and given ample time to provide lay and medical evidence in support of his claim. For these reasons, it is not prejudicial to the Veteran for the Board to proceed to finally decide this appeal as the notice defect in this case did not affect the essential fairness of the adjudication. Relevant to the duty to assist, the Veteran's service treatment records, as well as all post-service treatment records identified by the Veteran and the record have been obtained and considered. The Veteran has not identified any additional, outstanding records that he wishes to be considered in his appeal. The Board notes that the Veteran also has a Virtual VA paperless claims file, which is a highly secured electronic repository that is used to store and review documents involved in the claims process. The Board has reviewed the contents of the paperless file, including VA outpatient treatment records dated from 2012 to 2013, and it is apparent that the RO reviewed all evidence in the paperless claims file as well. The Board again notes that the Veteran was provided with several VA examinations in conjunction with the claims on appeal, and there is no allegation or indication that the examination or opinions rendered in this appeal were inadequate. See VA examination reports dated March 2010, April 2012, February 2013, and March 2013; see also addendum reports dated June 2013 and undated. Therefore, the Board will proceed with review of the Veteran's claims based upon all relevant evidence. Therefore, the Board concludes that VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claim, as additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran). II. Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a), including arthritis, and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition to the foregoing, service connection is also 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. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Left Knee and Lumbar Spine Review of the record reveals the Veteran has been diagnosed with osteoarthritis affecting the left knee and degenerative disc disease of the lumbar spine. See June 2013 Addendum to February 2013 VA examination report; see also x-ray reports dated April 2001, October 2010 and December 2012. The first element of service connection has been established. The Veteran has asserted that service connection is warranted for his current left knee and lumbar spine disabilities because they were incurred as a result of his military service. He has specifically asserted that his left knee and low back pain began in late 1965 while he was working as a plane handler on the flight deck/line of an aircraft carrier. The Veteran has reported that his duties including heavy lifting, pulling tow bars, and securing shocks and chains to hold down planes and that he worked 16 hours days each day, which progressively affecting his back and left knee. See April 2006 statement from the Veteran; November 2012 hearing transcript. The Veteran has also reported that his left knee and low back pain have been continuously disabling since service. See January 2007 statement from the Veteran. In this regard, the Veteran testified that he lived with his left knee and lumbar spine pain after service until he started receiving treatment from VA in approximately 2003. See November 2012 hearing transcript. Due to the similar medical history and evidence related to the Veteran's claims involving his left knee and low back/lumbar spine, as well as the similar disposition of the issues, the Board will address them in a common discussion. The Veteran's service treatment records (STRs), including the November 1967 separation examination, do not contain any complaints, treatment, or diagnosis of disabilities involving the left knee or low back. Nevertheless, the Veteran is competent to report the onset, frequency, and severity of his symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). In this regard, the Board also notes that the Veteran's DD Form 214 reflects that his military occupational specialty (MOS) was an aviation boatswain's mate (aircraft handling). As such, the Board finds that the Veteran's report of lifting heavy items, pulling tow bars, and securing shocks and chains to hold down planes during service is consistent with the circumstances and conditions of his service, and is, therefore, sufficient proof that he performed those duties during service. See 38 U.S.C.A. § 1154(a). While this evidence does not conclusively establish that the Veteran experienced left knee and lumbar spine symptoms during service, this evidence tends to corroborate his report of experiencing such symptoms during service. Therefore, the lay evidence provided by the Veteran is considered competent lay evidence, as it purports to establish that the Veteran manifested left knee and lumbar spine symptoms during and since service and, in evaluating this claim, the Board finds the Veteran's testimony at the November 2012 hearing to be particularly probative with respect to why he did not seek treatment for his left knee and lumbar spine pain immediately after service. As such, the Board also finds that the lay statements submitted in support of this claim are also credible for the purpose of establishing the onset of left knee and lumbar spine symptoms during and since service, and the second element of service connection is established. In February and March 2013, the Veteran was afforded VA examinations to evaluate his current left knee and lumbar spine disabilities; the diagnoses of left knee osteoarthritis and degenerative disc disease of the lumbar spine were continued. In June 2013, the physician who conducted the previous VA examinations provided an addendum report wherein she noted she reviewed the claims file and opined that the Veteran's current left knee and lumbar spine disabilities were at least as likely as not related to his military service. In making this determination, the VA examiner stated that there are several factors or precipitating causes of the current left knee and lumbar spine disabilities, but she concluded that the Veteran's military duties could have caused physical stress on his weight-bearing joints and that, because the knee and lumbar spine are weight-bearing joints, and thus, vulnerable, the everyday loading of these joints is necessary to cause a reaction and development or formation of osteoarthritis. The Board finds that the June 2013 VA opinion is the most competent, credible, and probative evidence of record with respect to the likely etiology of the Veteran's current left knee and lumbar spine disabilities. Indeed, it appears that the June 2013 opinion was based upon an adequate evaluation of the Veteran's left knee and lumbar spine, as reflected in the February and March 2012 examination reports, as well as review of the claims file. In this regard, it appears that the VA examiner was aware of all relevant facts in this case, as she provided a rationale in support of her conclusion, which is supported by the other evidence of record. In this context, the Board notes that there is competent and credible lay evidence of left knee and lumbar spine pain during and after service, which indicates that the current left knee and lumbar spine disabilities are related to his military service. In evaluating the merits of this claim, the Board also notes that there is no other medical evidence or opinion of record which contradicts the findings of the VA examiner. Therefore, based on the foregoing, the Board concludes that service connection for left knee and lumbar spine arthritis is warranted, as the most competent, credible, and probative evidence of record shows that his current left knee and lumbar spine disabilities were incurred as a result of his military service. In making this determination, all reasonable doubt has been resolved in favor of the Veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Chronic Fatigue Syndrome A review of the Veteran's service treatment records shows that no complaints or treatment for chronic fatigue syndrome in service of for many years after service. Service connection on a direct basis is not warranted, however, the Veteran does not allege that chronic fatigue syndrome was incurred in or as a direct result of his military service. Instead, the Veteran has asserted that service connection should be granted for chronic fatigue syndrome as secondary to service-connected hepatitis C. Review of the record shows that the Veteran has variously complained of fatigue throughout the pendency of this claim and appeal. See VA treatment records dated June 2006, September 2006, and January 2008. Notably, the evidence reflects that the Veteran's complaints of fatigue were made in conjunction with treatment for his hepatitis C disability, but a diagnosis of chronic fatigue syndrome had not been established. See VA treatment records dated from 2003 to 2013. Indeed, review of the record reveals the Veteran was provided a VA examination in February 2013 to determine if he has a current diagnosis of chronic fatigue syndrome that is related to his hepatitis C disability. At that time, the VA examiner noted that the Veteran has a diagnosis of chronic fatigue secondary to liver cirrhosis and hepatitis C, noting that the Veteran has reported feeling tired since being diagnosed with hepatitis C in the 1980s. The VA examiner also noted that the Veteran experiences generalized muscle aches, fatigue lasting 24 hours or more, headaches, and sleep disturbance. Nevertheless, the VA examiner opined that the Veteran does not have a diagnosis of chronic fatigue syndrome, as his hematologic changes and encephalopathy are most likely causing his fatigue, as opposed to chronic fatigue syndrome. The VA examiner also noted that tiredness is one of the early symptoms of hepatitis C. In this regard, the examination report notes that, for VA purposes, a diagnosis of chronic fatigue syndrome requires the exclusion, by history, physical examination, and laboratory tests, of all other clinical conditions that may produce similar symptoms, among other things. Based upon the examination, the Veteran did not meet the required number of symptoms. The Board considers the February 2013 VA examination and opinion to be the most competent, credible, and probative evidence of record with respect to whether the Veteran currently has a diagnosis of chronic fatigue syndrome, as opposed to merely symptoms of fatigue that are attributable to other conditions. The Board finds that the February 2013 VA examination was adequate for evaluation purposes, as the examiner reviewed the claims file, interviewed the Veteran, and conducted a physical examination. There is also no indication or allegation that the VA examiner was not fully aware of all relevant facts in this case or that he misstated any relevant fact. In fact, the VA examiner provided an opinion that was supported by a complete rationale and based upon the other evidence of record which shows complaints of fatigue are primarily related to his hepatitis C and other disabilities, and that the Veteran does not have chronic fatigue syndrome. Simply stated, the evidentiary record does not contain any competent and credible lay or medical evidence of record which shows the Veteran's complaints of fatigue have resulted in a clinical diagnosis of chronic fatigue syndrome or are more appropriately diagnosed as such. Without proof of the existence of the disability being claimed, there can be no valid claim. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Degmitech v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Therefore, based on the foregoing reasons and bases, the Veteran's claim of service connection for chronic fatigue syndrome must be denied, and there is no reasonable doubt to be resolved. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. ORDER Entitlement to service connection for left knee arthritis is granted. Entitlement to service connection for lumbar spine arthritis is granted. Entitlement to service connection for chronic fatigue syndrome is denied. REMAND As noted in the Introduction, in December 2012, the Board remanded the claims on appeal for additional evidentiary development, to specifically include scheduling the Veteran for a VA examination and opinion. As to the claimed prostatitis, respiratory disorder (shortness of breath and OSA), and hypertensive vascular disease, the Board directed that a medical opinion be obtained with respect to whether each of the claimed disabilities is related to his military service, or his service-connected PTSD, hepatitis, or cirrhosis of the liver. See December 2012 Board remand. Review of the record reveals the Veteran was afforded with appropriate examinations upon remand, after which he was diagnosed with prostatitis, OSA, with no evidence of any other respiratory disability, and hypertensive heart disease. See VA examination reports dated March 2013. The VA examiner opined, however, that the Veteran's hypertensive heart disease is less likely than not proximately due to, a result of, or aggravated by cirrhosis of the liver and hepatitis C, noting that the Veteran has had uncomplicated essential hypertension which has been well controlled since 1999. The VA examiner did not, however, address whether the Veteran's hypertensive heart disease is less likely than not proximately due to, a result of, or aggravated by his service-connected psychiatric disorder, as directed by the Board. The U.S. Court of Appeals for Veterans Claims has held that compliance by the Board or the RO with remand instructions is neither optional nor discretionary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Therefore, based on the foregoing, the Board finds that the directives of the December 2012 remand were not substantially complied with, thereby necessitating another remand. Indeed, on remand, the VA examiner will be requested to address whether the Veteran's hypertensive heart disease is less likely than not proximately due to, a result of, or aggravated by his service-connected psychiatric disorder. In addition, the Board notes that it is not clear if the VA examiner considered all relevant facts before rendering his opinion with respect to the claimed hypertensive vascular disease. In this regard, while the VA examiner noted that the Veteran has uncomplicated essential hypertension, the record reflects that the Veteran has been diagnosed with portal hypertension, which has been attributed to his cirrhosis of the liver. See April 2012 Hepatitis C VA examination; January 2008 VA outpatient treatment record. The VA examiner did not address the evidence showing that the Veteran's portal hypertension is related to his cirrhosis and there is no other evidence of record which addresses this issue. Therefore, the Board finds that an addendum report is needed in order for the examiner to address whether the evidence showing portal hypertension due to cirrhosis of the liver supports a finding that the Veteran's claimed hypertensive vascular disease is proximately due to, a result of, or aggravated by his service-connected cirrhosis of the liver and hepatitis C. As to prostatitis, the VA examiner opined that prostatitis is less likely than not proximately due to, a result of, or aggravated by cirrhosis of the liver and hepatitis C, noting that there is no scientifically based medical literature associating cirrhosis of the liver and hepatitis C with chronic prostatitis or benign prostatic hypertrophy. The VA examiner did not, however, address whether the Veteran's prostatitis is less likely than not proximately due to, a result of, or aggravated by his service-connected psychiatric disorder, as directed by the Board. See Undated Addendum; see also Stegall, supra. As such, on remand, the VA examiner will be requested to address whether the Veteran's prostatitis is secondary to his service-connected psychiatric disorder. As to the etiology of the Veteran's OSA, the VA examiner also opined that the disability was less likely as not incurred in or aggravated by an injury, event, or illness in service, and he provided a negative nexus opinion with respect to secondary service connection, noting that PTSD, cirrhosis, and hepatitis disabilities do not cause upper airway obstruction during sleep. See March 2013 VA examination report; see also Stegall, supra. The VA examiner did not, however, address whether the Veteran's OSA is likely aggravated by his service-connected disabilities, as directed by the Board. In this regard, the Board notes that a VA opinion that a service-connected disability did not cause the non-service-connected disability is an insufficient opinion when aggravation has been claimed. See Allen v. Brown, 7 Vet. App. 439 (1995); see also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (holding that once VA undertakes the effort to provide an examination for a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). Therefore, on remand, the RO will be requested to obtain an amended medical opinion that addresses whether the Veteran's OSA is aggravated by his service-connected psychiatric, hepatitis C, and cirrhosis disabilities. Finally, the evidentiary record, including the paper and paperless claims files, contains VA treatment records dated from 2003 to July 2013. Upon remand, the RO/AMC should also obtain all outstanding VA treatment records dated from July 2013 to the present and associate them with the claims file. On remand, the RO/AMC should also ensure that the Veteran has been provided with adequate VCAA notice with respect to his secondary service connection claims. 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) (2012). Expedited handling is requested.) 1. Ensure that all VCAA notice required by 38 U.S.C.A. § 5103a and 38 C.F.R. § 3.159 are fully complied with. Dingess v. Nicholson, 19 Vet. App. 473 (2006). 2. Obtain VA treatment records dated from July 2013 to the present and associate them with the claims file. 3. Request that the physician who conducted the VA genitourinary, heart, and respiratory examinations in February 2013 review the claim s file, including this remand, and provide an addendum to the previous examination report that addressees the following: With respect to hypertensive heart/vascular disease: a. Is it at least as likely as not (i.e., there is a 50 percent or greater probability) that hypertensive heart disease is proximately due to or the result of his service-connected psychiatric disability? b. Is it at least as likely as not (i.e., a probability of 50 percent) that hypertensive heart disease is aggravated by his service-connected psychiatric disability? c. In answering the foregoing, the examiner should address the evidence showing the Veteran has been diagnosed with portal hypertension, which has been attributed to his cirrhosis of the liver. See April 2012 Hepatitis C VA examination; January 2008 VA outpatient treatment record. d. The examiner should also note that aggravation connotes a permanent worsening above the base level of disability, not merely acute and transitory increases in symptoms or complaints. With respect to prostatitis: a. Is it at least as likely as not (i.e., there is a 50 percent or greater probability) that hypertensive heart disease is proximately due to or the result of his service-connected psychiatric disability? b. Is it at least as likely as not (i.e., a probability of 50 percent) that hypertensive heart disease is aggravated by his service-connected psychiatric disability? With respect to obstructive sleep apnea, is it at least as likely as not (i.e., there is a 50 percent or greater probability) that hypertensive heart disease is proximately due to or the result of his service-connected psychiatric disability? A rationale must be provided for each opinion offered. If the foregoing cannot be answered on a medical or scientific basis and without invoking processes relating to guesses or judgment based upon mere conjecture, the examiner should clearly and specifically so specify in the report and explain why this is so. 4. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs