Citation Nr: 1400136 Decision Date: 01/02/14 Archive Date: 01/16/14 DOCKET NO. 10-05 578 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to a service-connected disability. 2. Entitlement to service connection for a deviated septum, to include as secondary to a service-connected disability. 3. Entitlement to service connection for sinusitis, to include as secondary to a service-connected disability. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD S. Becker, Counsel INTRODUCTION The Veteran served on active duty from September 2000 to September 2006. This matter comes before the Board of Veterans' Appeals (Board) from a July 2009 rating decision in which the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska denied service connection for a deviated septum, esophageal reflux, chronic maxillary and ethmoid sinusitis, allergic rhinitis, and sleep apnea. The Veteran appealed each of these determinations. Jurisdiction was then transferred to the RO in Waco, Texas. The Veteran testified on this matter at a videoconference hearing before the undersigned in May 2012. In June 2012, the Board granted service connection for allergic rhinitis and sleep apnea and remanded the claims for service connection for a deviated septum, GERD, and sinusitis for additional development. This development has been completed or at least substantially completed. Adjudication of these issues may proceed if otherwise in order. Dyment v. West, 13 Vet. App. 141 (1999), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002); Stegall v. West, 11 Vet. App. 268 (1998). No potential problems with adjudication are found at this time with respect to service connection for GERD. As such, the following decision is made for this issue based on review of the Veteran's paper claims file and Virtual VA electronic claims file. This review shows that more additional development is needed with respect to the claim for service connection for a deviated septum and sinusitis. These issues are once again REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The Veteran's current GERD is not related in any manner to his service or to his service-connected disabilities. CONCLUSION OF LAW The criteria for establishing service connection for GERD have not been met. 38 U.S.C.A. §§ 1110, 1111, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist Before addressing the merits of service connection for GERD, the Board notes that VA has a duty of notification regarding a claim for VA benefits. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159. VA must provide notice prior to initial adjudication of the evidence necessary to substantiate the benefit(s) sought, that VA will seek to obtain, and that the claimant should provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Notification of how a rating and an effective date will be assigned if service connection is granted also must be included. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Neither the Veteran nor his representative has alleged prejudice concerning notice, as is required. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (overturning Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007)). None is found. Via a May 2009 letter, the Veteran and his representative were informed of the criteria necessary to establish service connection on a direct basis, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. The letter also informed them of how VA assigns a rating and effective date if service connection is granted. It was sent on time prior to the July 2009 rating decision which constituted the initial adjudication. A June 2012 letter, which was sent pursuant to the Board's remand, repeated the aforementioned as well as informed the Veteran and his representative of the criteria necessary to establish secondary service connection. To the extent supplemental information at this juncture constituted a timing error, it has been cured by later readjudication in an October 2012 supplemental statement of the case. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Prickett v. Nicholson, 20 Vet. App. 370 (2006). In addition to the duty to notify, VA has a duty to assist with respect to a claim for VA benefits. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This includes, as implied from the notification that must be provided, a requirement to aid the claimant in the procurement of relevant records. 38 U.S.C.A. §§ 5103A(b-c); 38 C.F.R. §§ 3.159(c)(1-3). VA also is required to provide a medical examination and/or obtain a medical opinion when necessary. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Service treatment records have been obtained by VA. One exception is a portion of his entrance examination, for which a formal finding of unavailability was made in June 2009 because all efforts to obtain it including from the Veteran had been exhausted. He has had opportunities, such as responding to the aforementioned letters, to identify relevant VA and private treatment records. However, he has not identified any pertinent VA treatment records. Pertinent treatment records from all private health care providers identified by him have been obtained by VA. Some duplicates also were submitted by him on his own behalf. In addition, the Veteran submitted letters from one of these providers. Pursuant to the Board's remand, he underwent a VA medical examination with a medical opinion in August 2012. The examiner reviewed the paper claims file, but there is no indication whether or not the electronic claims file was reviewed. To the extent it was not reviewed, it is of no great import. All documentation in it is procedural in nature. The examiner further was aware of the Veteran's relevant medical history because he recounted such. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); D'Aries v. Peake, 22 Vet. App. 97 (2008). He also was interviewed by each concerning his current state. The examiner then performed a physical assessment of him. These actions have provided sufficient detail so that the decision made herein is fully informed. The examination thus is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). For the foregoing reasons, the Board finds that VA's duties to notify and assist have been satisfied. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). It follows that no further notice or assistance is required. This means that adjudication may proceed without prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384 (1993). Doing so is fair to him since VA has notified him regarding this matter and has assisted in obtaining evidence with respect to it, in other words. Of final note before addressing the merits, the individual presiding over a hearing must fully explain the issues and suggest the submission of evidence that may have been overlooked. 38 C.F.R. § 3.103(c)(2); Bryant v. Shinseki, 23 Vet. App. 488 (2010). The undersigned identified service connection for GERD as being among the issues on appeal at the beginning of the May 2012 videoconference hearing. The undersigned and the Veteran's representative then elicited information from him concerning a possible relationship between this disability and his service or his service-connected disabilities. Information also was elicited from him concerning his treatment for this disability, but none for which records had not already been obtained was noted. II. Service Connection Service connection means that the facts, shown by evidence, establish that an injury or disease resulting in disability was incurred in service, or if preexisting service, was aggravated therein. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). To establish service connection, there generally must be a current disability, the in-service incurrence or aggravation of an injury or disease, and a nexus between the current disability and the in-service disease or injury. Hickson v. West, 12 Vet. App. 247 (1999); Barr, 21 Vet. App. at 303. Service connection also may be established for any disease diagnosed after separation from service if it was incurred in service. 38 C.F.R. § 3.303(d). Secondary service connection means that a current nonservice-connected disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). To establish service connection on a secondary basis, there must be a current disability and a causation or aggravation nexus between it and a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). With respect to aggravation, the baseline level of disability pre-aggravation must be compared to the current level of disability. 38 C.F.R. § 3.310(b). Compensation is paid only for the degree over and above the baseline plus natural progression. Id.; Allen, 7 Vet. App. at 439. There must be a permanent worsening beyond natural progression of the disability, rather than temporary or intermittent flare-ups. Davis v. Principi, 276 F.3d 1341 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292 (1991). The Board must identify the evidence it finds to be persuasive and unpersuasive and explain why any favorable evidence is unpersuasive. Gabrielson v. Brown, 7 Vet. App. 36 (1994), Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Both medical and lay evidence (also known as non-medical evidence) may be discounted in light of inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). When there is an approximate balance of positive and negative evidence regarding any point, the claimant is afforded the benefit of the doubt. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. The claimant thus prevails on that point when the evidence supports the claim or is in relative equipoise but does not prevail when the preponderance of the evidence is against the claim. Only the most salient and relevant evidence must be discussed, although all the evidence must be and thus has been reviewed. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Based on this evidence, it is undisputed that the Veteran currently has GERD. A current disability exists when there is a disability either at, or contemporary to, the time the claim is filed or at any time during the pendency of the claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). The Veteran filed the instant claim in May 2009. Near contemporaneous treatment records from private Dr. W.D. dated in April 2009 contain a diagnosis of esophageal reflux. GERD similarly was diagnosed at the August 2012 VA medical examination. Service treatment records show that the Veteran's abdomen and viscera was found to be normal at his August 2000 entrance examination. It is unknown whether or not he complained of any pertinent symptoms at that time because this part of his entrance examination formally has been found to be unavailable. However, nothing suggests that the aforementioned normal finding was inaccurate. A few private treatment records dated prior to the Veteran's service are included with his service treatment records. They do not make any mention of GERD or pertinent symptoms. The Veteran accordingly is presumed to have been in sound condition when he began his service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). He is presumed not to have had GERD at that time, in other words. It follows that there was no preexisting disease that could have been aggravated during service. The question therefore is whether or not there was incurrence of a disease during service. The Veteran contends that he experienced pertinent symptoms, particularly acid indigestion and heartburn or a burning sensation in the area of his ribcage, during service. He further contends that he did not seek treatment for these symptoms, instead taking over-the-counter medication, because he attributed them simply to bad eating habits. Lay evidence is competent when it relates that which is personally experienced or observed. Layno v. Brown, 6. Vet. App. 465 (1994). The Veteran is competent to recount the aforementioned because such would have been experienced by him personally. Competent lay evidence may be discounted due to factors such as interest, self-interest, bias, inconsistent statements, inconsistency with other evidence of record, facial implausibility, bad character, malingering, desire for monetary gain, and witness demeanor. Pond v. West, 12 Vet. App. 341 (1999); Macarubbo v. Gober, 10 Vet. App. 388 (1997); Caluza v. Brown, 7 Vet. App. 498 (1995); Cartright v. Derwinski, 2 Vet. App. 24 (1991). Here, the Veteran is credible because none of these factors are significant. Obviously, the Veteran is self-interested in this decision. A favorable decision would raise the potential of additional compensation being paid to him. However, nothing suggests that his desire for compensation is his primary motivation in asserting that he experienced pertinent in-service symptoms for which he did not seek treatment. The Veteran's demeanor at the May 2012 hearing rather suggested he was being truthful. His recounts there and elsewhere are consistent with one another and facially plausible. They are not inconsistent with the other evidence. Service treatment records are silent with respect to GERD and pertinent symptoms. This lack of supporting contemporaneous medical evidence is not enough to find the Veteran lacking in credibility. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). He denied having frequent indigestion during and immediately after his deployment abroad from August to October 2004, but the rest of his service was not referenced. He also denied having suffered from any illness during service for which he did not seek medical care at his July 2006 separation examination. However, this is readily explained by the fact that he may not have considered his symptoms to be an illness. He may have believed them to be common to the general population, for example. Or he may not have believed them to be severe or frequent enough to constitute a serious problem. GERD finally was not diagnosed at the separation examination. Yet that does not mean the Veteran did not have pertinent symptoms at some other point during his service. It is clear that the Veteran believes there is a relationship between his pertinent in-service symptoms and his current GERD. He also believes there is a relationship between his service-connected allergic rhinitis or sleep apnea and his current GERD. Lay evidence sometimes can be sufficient to prove nexus. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010); Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). However, the question of whether there exists a relationship to service in this case falls outside the province of a lay person and is a medical question. Of import are the complexities of the digestive system in general, the numerous causes of GERD specifically, and intricacies of how allergic rhinitis and sleep apnea impact the rest of the body. Only those with a medical background are competent where the determinative issue is medical. Jones v. West, 12 Vet. App. 460 (1999). The Veteran is not competent to render an opinion that there exists a relationship between his current GERD and his service, service-connected allergic rhinitis, or service-connected sleep apnea. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Lacking competence, his credibility in this regard need not be addressed. At the August 2012 VA medical examination, the Veteran stated that an ear, nose, and throat doctor told him that allergies can caused GERD. He did not name this doctor or provide great detail as to what the doctor actually said to him. A lay person's account of what a medical professional purportedly told him, in any event, is not medical evidence. Robinette v. Brown, 8 Vet. App. 69 (1995). Two private opinions are of record. Dr. W.D. opined in a May 2009 letter that it could be stated with a reasonably degree of medical certainty that the Veteran's current GERD is interrelated to his sleep apnea in that it makes his sleep apnea worse. In a September 2009 letter, Dr. W.D. opined that it is more likely than not that the Veteran's exposure to allergens during service caused his current GERD to worsen. One VA medical opinion also is of record. The examiner who conducted the August 2012 VA medical examination opined that the Veteran's current GERD is less likely than not related to his service, service-connected allergic rhinitis, or service-connected sleep apnea. Dr. W.D.'s May 2009 opinion is inapposite. At issue is whether or not the Veteran's service-connected sleep apnea either caused or aggravated his current GERD. Whether or not his current GERD aggravates his service-connected sleep apnea, as Dr. W.D. has opined, therefore does not factor into this decision. It follows that it is unnecessary to further discuss his aforementioned opinion. Discussion of Dr. W.D.'s September 2009 opinion and the August 2012 VA medical opinion is necessary. A medical opinion may be discounted due to factors such as the qualifications and expertise of the individual rendering the opinion, the scope of the assessment, review of pertinent evidence, the accuracy of the factual premises underlying the opinion, the rationale provided for it, and degree of certainty in it. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Prejean v. West, 13 Vet. App. 444 (2000); Ardison v. Brown, 6 Vet. App. 405 (1994); Reonal v. Brown, 5 Vet. App. 458 (1993); Guerrieri v. Brown, 4 Vet. App. 467 (1993). None of these factors are significant with respect to the VA medical opinion, but several are significant with respect to Dr. W.D.'s September 2009 opinion. The VA examiner identified herself as a certified physician assistant. Her qualifications and expertise have not been challenged by the Veteran or his representative, and therefore she is presumed competent. Rizzo v. Shinseki, 580 F.3d 1288 (Fed. Cir. 2009); Cox v. Nicholson, 20 Vet. App. 563 (2007); Hilkert v. West, 12 Vet. App. 145 (1999). That at least the paper claims file was reviewed by her and that she interviewed the Veteran regarding his medical history, as well as his current symptoms, is reiterated. There is no indication of any deficiency with the scope of her assessment of the Veteran. The VA examiner used unequivocal language in expressing her opinion. Her rationale was that there is no documentation of pertinent symptoms during the Veteran's service and that he was diagnosed approximately three years after he separated from service. It also was noted that medical literature supports a link between GERD being caused by food allergies but not other allergies and does not support allergic rhinitis or sleep apnea aggravating GERD. The impact of various medications taken by the Veteran for allergic rhinitis, since he takes none for sleep apnea, finally was considered. Regarding the accuracy of the aforementioned factual premises evident in the rationale, there is no reason for doubt with one exception. The above finding that the Veteran experienced pertinent symptoms during service is reiterated. The VA examiner's finding to the contrary thus is incorrect. However, it is clear that in-service pertinent symptoms were considered. The Veteran's recount of such indeed was set forth in the summarization of his interview. It further is clear that the same opinion would have been rendered even if in-service pertinent symptoms had been accepted as fact. The VA examiner indeed stressed that GERD was not diagnosed until three years after the Veteran's separation from service. A significant period of time without manifestation of pertinent symptoms weighs against service connection. Maxson v. West, 12 Vet. App. 453 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). That the Veteran continued to experience pertinent symptoms at least on occasion subsequent to his service, as he contends, is likely. Indeed, it is common knowledge that indigestion and heartburn are experienced by many individuals from time to time. Continuity of treatment, as opposed to continuity of symptomatology, is not for consideration. Savage v. Gober, 10 Vet. App. 488 (1997). Yet it is telling here that the Veteran did not seek treatment for his pertinent symptoms until a few years following his separation. His coworker W.B. did not mention these symptoms in relation to the period immediately after his service in a September 2009 statement. Neither did his wife L.G. in relation to the entire period subsequent to his service. Other symptoms were mentioned. As such, it is inferred that he most likely did not complain often of pertinent symptoms because he was not experiencing them. All indications thus are that they became a serious problem well after his service. Dr. W.D., as a physician, undisputedly has the sufficient qualifications and expertise. His letter mentioned review of the Veteran's service treatment records and "personal medical records." What these latter records are is unclear, but it is presumed that Dr. W.D. at least reviewed his own treatment records of the Veteran. Dr. W.D. did not perform an assessment solely for the purpose of rendering an opinion, like the VA examiner, but there is no indication of any deficiency with the scope of the assessments conducted for treatment purposes. Unequivocal language was used in expressing the opinion. No reason to doubt the accuracy of the factual premise underlying the opinion, exposure to allergens during service, exists. Such exposure is conceded. It is unclear exactly what Dr. W.D. means by stating that this exposure caused the Veteran's current GERD to worsen. Preexisting GERD is implied therefrom, but this is incorrect as a contrary finding was made above. In any event, greater discussion in this regard is unnecessary. Other than the mention of in-service exposure to allergens, no other rationale was provided. A medical opinion is not entitled to any probative value if it is not supported by a rationale. Nieves-Rodriguez, 22 Vet. App. at 295. Thus, Dr. W.D.'s September 2009 opinion is assigned little to no weight. The VA medical opinion, in contrast, is assigned substantial weight. It indeed is very persuasive and outweighs the Veteran's statements and testimony to the extent they are in conflict. In sum, the preponderance of the evidence is against service connection for GERD in any manner for each of the foregoing reasons. As such, there is no benefit of the doubt to afford to the Veteran. He thus must denied the aforementioned benefit sought. ORDER Service connection for GERD is denied. REMAND While the Board regrets the delay entailed by another remand, adjudication of the Veteran's entitlement to service connection for a deviated septum and for sinusitis cannot proceed at this time. Additional development is needed to ensure that he is afforded every possible consideration. VA's duty to assist him in substantiating the benefit claimed indeed is reiterated. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. I. Records Compliance with the duty to assist requires that VA make reasonable efforts to assist in the procurement of relevant records. 38 U.S.C.A. § 5103A(b); 38 C.F.R. § 3.159(c). When the existence of records that are not in the government custody is discovered, the claimant must be requested to either submit them to VA or provide enough information to identify and locate them along with an authorization for their release to VA. 38 C.F.R. §§ 3.159(c)(1), (e)(2). If information and authorization is provided, reasonable efforts consist of an initial request and one or more follow-up requests if necessary. 38 C.F.R. § 3.159(c)(1). The claimant shall be notified if requested records cannot be or are not obtained. 38 U.S.C.A. § 5103A(b)(2); 38 C.F.R. § 3.159(e)(1). Discussed above was that pertinent treatment records from all private health care providers are available because he submitted them as well as took advantage of opportunities to identify them so that they could be obtained on his behalf. The duty to assist therefore has been fulfilled as it pertains to these records. VA is not obligated to do anything more in this regard, in other words. However, it is notable that the most recent pertinent private treatment record is dated in February 2010. A significant possibility exists that there are outstanding pertinent private treatment records dated during the almost four years that have passed since then. An opportunity will be provided to the Veteran to either submit them or provide enough information to locate them along with authorization for their release to VA since a remand is necessary for another reason. If he opts to provide information along with authorization, an initial request for the applicable pertinent private treatment records must be made. Follow-up requests and notification to him and his representative if they are unsuccessful also must be made as necessary. II. Medical Examination and Opinion As noted above, a VA medical examination or opinion obtained pursuant to the duty to assist in conjunction with a service connection claim must be adequate. Barr, 21 Vet. App. at 303. A VA medical examination or VA medical opinion is adequate when it allows for fully informed adjudication. Id. The disability present, if any, must be described in sufficient detail during the examination. Stefl, 21 Vet. App. at 120; Ardison, 6 Vet. App. at 405. Consideration must be given to the Veteran's entire medical history in formulating the opinion. Stefl, 21 Vet. App. at 120; Ardison, 6 Vet. App. at 405. This helps ensure that the factual premises underlying the opinion is accurate, as is required. Reonal, 5 Vet. App. at 458. The rationale provided for it further must be clear and complete. Nieves-Rodriguez, 22 Vet. App. at 295; Stefl, 21 Vet. App. at 120. All applicable theories of entitlement must be addressed, whether in it or otherwise. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009); Szemraj v. Principi, 357 F.3d 1370 (Fed. Cir. 2004). The Board's prior remand directives were crafted so as to comply with the duty to assist. Specifically, it was directed that the Veteran undergo a VA medical examination complete with VA medical opinions concerning whether or not he has a deviated septum and sinusitis related to his service or to his service-connected allergic rhinitis or sleep apnea. A VA medical examination complete with medical opinions accordingly was conducted in September 2012. Deviation of the Veteran's nasal septum ultimately was noted, but no diagnosis was made of chronic sinusitis of any kind. It indeed was indicated that physical assessment revealed no evidence of chronic sinusitis. Also indicated was that chronic sinusitis was not shown on a July 2012 computerized tomography (CT) scan. The lack of a current disability formed the basis for the examiner's opinion that sinusitis is not related to the Veteran's service. The examiner finally opined that the Veteran's deviated septum is not related to his service. The basis was that service treatment records do not document nasal trauma, and there is no indication otherwise of a link between the deviated septum and service. No problems are evident with the aforementioned examination. The same cannot be said regarding either of the associated opinions, however. Set forth above was that a current disability need be present only at some point from the time the claim is filed until the time it is finally resolved. McClain, 21 Vet. App. at 319. Here, the April 2009 treatment records from private Dr. W.D. contain diagnoses of chronic maxillary sinusitis and chronic ethmoid sinusitis made after a contemporaneous CT scan showed findings consistent therewith. The factual premise for the opinion regarding sinusitis accordingly is inaccurate because it fails to account for the Veteran's entire pertinent medical history. The opinion further considers only whether or not there is a relationship between sinusitis and service. No consideration was given to whether or not there was a relationship between sinusitis and the Veteran's service-connected allergic rhinitis or sleep apnea. With respect to the opinion regarding a deviated septum, there similarly was consideration only of a relationship to service with no consideration of a relationship to service-connected allergic rhinitis or sleep apnea. The directives of the Board's prior remand thus were not complied with, as is required. Stegall, 11 Vet. App. at 268. Adjudication at this time based on the VA medical opinions accompanying the September 2012 VA medical examination, in sum, would not be fully informed. It follows that arrangements must be made for another VA examination complete with opinions. Given the above, a REMAND is directed for the following: 1. Ask the Veteran either to submit his private treatment records concerning sinusitis dated from February 2010 to present or to provide enough information to locate them along with an authorization for their release to VA. If he provides the information and authorization, make an initial request for the records with a follow-up request or requests as necessary. Associate all records received with the paper or electronic claims file. If requested records ultimately are not received or are received but are incomplete, notify the Veteran and his representative pursuant to established procedure. Document such notification in the paper or electronic claims file. 2. After completion of the above, arrange for the Veteran to undergo an appropriate VA medical examination regarding sinusitis and his deviated septum. The examiner shall review the paper and electronic claims files, documenting such in a report to be placed in one of these files. The examiner also shall document in the report an interview with the Veteran regarding the onset, frequency, duration, and severity of his relevant symptoms. All tests and studies deemed necessary next shall be performed, the results of which shall be included in the report. This shall include, at a minimum for sinusitis, a CT scan. The examiner then shall render an opinion in the report as to whether the Veteran has had sinusitis at any time since around May 2009 when he filed his claim. The examiner also shall opine in the report as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's sinusitis, if diagnosed, as well as his deviated septum was incurred during his service, is related to his exposure to allergens during service, is related to his service in any manner otherwise, was either caused by or has been aggravated (permanently worsened beyond the natural progression) by his service-connected allergic rhinitis, or was either caused by or has been aggravated by his service-connected sleep apnea. If any aggravation is found, an opinion also is needed as to the level of disability prior to the aggravation and the current level of disability so that the amount due to aggravation can be established. A clear and complete rationale (explanation) for each opinion shall be provided by the examiner in the report. This includes a discussion of pertinent medical principles as they concern the pertinent medical and lay evidence. Dr. W.D.'s April 2009 treatment records containing diagnoses of sinusitis made following a CT scan specifically shall be taken into account. Continuity of symptomatology as documented in treatment records and reported by the Veteran and his wife L.G. in statements and testimony further specifically shall be taken into account. Finally, the impact of medication taken by the Veteran for his allergic rhinitis and sleep apnea shall be taken into account. If an opinion cannot be provided without resort to speculation, the rationale shall discuss whether this is due to a lack of the appropriate qualifications, the need for more information, the limits of current medical knowledge, the inability to select the cause among multiple potential causes, the inability to obtain needed information, or some other reason. A citation for or copy of any medical literature referenced shall be provided. 3. Finally, readjudicate the issues of entitlement to service connection for a deviated septum, to include as secondary to a service-connected disability, and entitlement to service connection for sinusitis, to include as secondary to a service-connected disability. For any determination made that is favorable to him, furnish him and his representative with a rating decision. For any determination made that is unfavorable to him, furnish him and his representative with a supplemental statement of the case (SSOC). Then allow them the requisite time period to respond before processing the aforementioned issue for return to the Board. Place a copy of the rating decision and/or SSOC in the paper or electronic claims file. No action is required of the Veteran until he is notified by the RO or AMC. However, he is advised that he is obligated to cooperate with VA in ensuring that the duty to assist is satisfied. Kowalski, 19 Vet. App. at 171; Wood, 1 Vet. App. at 190. His failure to report for a scheduled VA medical examination, for example, may result in denial of the benefit(s) sought. 38 C.F.R. § 3.655 (2013). He also is advised that he has the right to submit additional evidence and argument concerning the remanded issues of this matter. Kutscherousky v. West, 12 Vet. App. 369 (1999). The action directed herein must be undertaken promptly. The law indeed requires that all issues remanded by the Board or by the United States Court of Appeals for Veterans Claims be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). _________________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs