Citation Nr: 1513982 Decision Date: 04/01/15 Archive Date: 04/09/15 DOCKET NO. 14-17 828 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Whether new and material evidence has been received to reopen service connection for tinea cruris. 2. Whether new and material evidence has been received to reopen service connection for numbness and weakness of the left lower extremity. 3. Whether new and material evidence has been received to reopen service connection for breathing problems. 4. Whether new and material evidence has been received to reopen service connection for esophagus problems. 5. Whether new and material evidence has been received to reopen service connection for urinary problems. 6. Whether new and material evidence has been received to reopen service connection for enlarged liver. 7. Entitlement to service connection for tinea cruris, include as due to herbicide (Agent Orange) exposure. 8. Entitlement to service connection for numbness and weakness of the left lower extremity as secondary to the service-connected coronary artery disease disability. 9. Entitlement to service connection allergic rhinitis (previously claimed as breathing problems) as secondary to the service-connected mandible disability. 10. Entitlement to service connection for gastroesophageal reflux disease (GERD), (previously claimed as esophagus problems) as secondary to the service-connected mandible disability. 11. Entitlement to service connection for a urinary disorder, diagnosed as recurrent urinary tract infections, benign prostatic hypertrophy, and prostatitis, to include as due to herbicide (Agent Orange) exposure and as secondary to the service-connected mandible disability. 12. Entitlement to service connection for an enlarged liver, to include as due to herbicide (Agent Orange) exposure and as secondary to the service-connected mandible disability. 13. Entitlement to service connection for lipoma, to include as due to herbicide (Agent Orange) exposure. 14. Entitlement to special monthly compensation (SMC) at the housebound rate. 15. Entitlement to SMC based on the need for aid and attendance. 16. Entitlement to an initial rating in excess of 10 percent for coronary artery bypass graft with coronary artery disease beginning November 1, 2013. 17. Entitlement to an initial rating in excess of 10 percent for epiphora left eye. 18. Entitlement to an initial rating in excess of 10 percent for postoperative coronary artery bypass graft scar. 19. Entitlement to an initial compensable rating for bilateral hearing loss. 20. Entitlement to an increased rating in excess of 20 percent for residuals, gunshot wound of mandible. 21. Entitlement to an increased rating in excess of 10 percent for residuals, gunshot wound of 5th cranial nerve. 22. Entitlement to a compensable rating for donor site, left iliac crest. 23. Entitlement to service connection for renal cell carcinoma (claimed as kidney disease). 24. Entitlement to service connection for degenerative speech. 25. Entitlement to service connection for bilateral cataracts (also claimed as blurred and double vision). 26. Entitlement to service connection for a hernia. 27. Entitlement to service connection for diabetes mellitus type II associated with Agent Orange. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD R. Casadei, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1967 to September 1969. This matter comes on appeal before the Board of Veterans' Appeals (Board) from the August 2011, December 2011, and January 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. This appeal was processed using the Veterans Benefits Management System (VBMS). Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. In evaluating this case, the Board has also reviewed the "Virtual VA" system to ensure a complete assessment of the evidence. The Veteran testified before the undersigned in a January 2015 video conference Board hearing, the transcript of which is included in VBMS. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issues of (1) service connection for tinea cruris; (2) numbness and weakness of the left lower extremity; (3) service connection allergic rhinitis (claimed as breathing problems); (4) service connection for GERD (claimed as esophageal problems); (5) service connection for a urinary disorder; (6) service connection for lipoma; (7) entitlement to SMC based on the need for aid and attendance; (8) an initial rating in excess of 10 percent for coronary artery bypass graft with coronary artery disease beginning November 1, 2013; (9) an initial rating in excess of 10 percent for epiphora left eye; (10) an initial rating in excess of 10 percent for postoperative coronary artery bypass graft scar; (11) an initial compensable rating for bilateral hearing loss; (12) an increased rating in excess of 20 percent for residuals, gunshot wound of mandible; (13) an increased rating in excess of 10 percent for residuals, gunshot wound of 5th cranial nerve; (14) a compensable rating for donor site, left iliac crest; (15) service connection for renal cell carcinoma (claimed as kidney disease); (16) service connection for degenerative speech; (17) service connection for bilateral cataracts (also claimed as blurred and double vision); (18) service connection for hernia; (19) service connection for diabetes mellitus type II associated with Agent Orange; and (20) entitlement to special monthly compensation at the housebound rate are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. An unappealed February 1997 rating decision denied service connection for tinea cruris, numbness and weakness of the left lower extremity, breathing problems, esophagus problems, enlarged liver, and urinary problems. 2. The Veteran did not submit a timely notice of disagreement to the February 1997 rating decision. 3. The evidence received since the February 1997 rating decision relates to an unestablished fact necessary to substantiate the claims for service connection for tinea cruris, numbness and weakness of the left lower extremity, breathing problems, esophagus problems, enlarged liver, and urinary problems. 4. The Veteran engaged in combat with the enemy during service. 5. The Veteran does not have a currently diagnosed liver disorder. CONCLUSIONS OF LAW 1. The February 1997 rating decision, which denied service connection for tinea cruris, numbness and weakness of the left lower extremity, breathing problems, esophagus problems, enlarged liver, and urinary problems became final. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. § 20.1103 (2014). 2. The criteria to reopen the claim for service connection for tinea cruris are met. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156(a) (2014). 3. The criteria to reopen the claim for service connection for numbness and weakness of the left lower extremity are met. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156(a) (2014). 4. The criteria to reopen the claim for service connection for breathing problems are met. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156(a) (2014). 5. The criteria to reopen the claim for service connection for esophagus problems are met. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156(a) (2014). 6. The criteria to reopen the claim for service connection for urinary problems are met. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156(a) (2014). 7. The criteria to reopen the claim for service connection for enlarged liver are met. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156(a) (2014). 8. The criteria for service connection for a liver disorder are not met. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2014); 38 C.F.R. § 3.303 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). The notice requirements of VCAA require VA to notify the claimant 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, the VA will attempt to obtain. The claims to reopen service connection have been considered with respect to VA's duties to notify and assist. Given the favorable outcome of this decision (reopening of service connection for tinea cruris, left lower extremity numbness and weakness, breathing problems, esophagus problems, urinary problems, and enlarged liver), no conceivable prejudice to the Veteran could result from this decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the 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, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In letters dated in July 2010, September 2010, October 2011, July 2012 the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate a claim for service connection, as well as what information and evidence must be submitted by the Veteran and what evidence VA would obtain. The notices included provisions for disability ratings and for the effective date of the claim. The July 2010 notice included information regarding secondary service connection. The Veteran's service treatment records, VA treatment records, the January 2015 Board hearing transcript, and the Veteran's statements are associated with the claims file. The Veteran was also afforded a VA examination in September 2010 in connection with his service connection claim for a liver disorder. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA opinion and findings obtained in this case are adequate. The VA opinion provided considered all the pertinent evidence of record, the Veteran's statements, and provide a complete rationale for the opinions stated. Significantly, the Veteran and his representative have not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). New and Material Evidence-Law and Analysis In a February 1997 rating decision, the RO denied service connection for tinea cruris, numbness and weakness of the left lower extremity, breathing problems, esophagus problems, enlarged liver, and urinary problems because there was no evidence that these disorders were incurred in service or were related to in-service Agent Orange exposure. The Veteran was properly notified of the February 1997 rating decision, did not initiate an appeal within one year of notice, additional relevant evidence was not received within one year of notice, and the decision became final. 38 U.S.C.A. § 7105(c); 38 C.F.R. § 20.1103. During the January 2015 Board hearing, the Veteran testified that he did not receive notice of the February 1997 rating decision. In this regard, there is a presumption of regularity under which it is presumed that government officials "have properly discharged their official duties." United States v. Chemical Foundation, Inc., 272 U.S. 1, 14-15 (1926); Mindenhall v. Brown, 7 Vet. App. 271, 274 (1994) (VA need only mail notice to the last address of record for the presumption to attach). This presumption of regularity in the administrative process may be rebutted by "clear evidence to the contrary." Schoolman v. West, 12 Vet. App. 307, 310 (1999). An allegation of non-receipt, by itself, is insufficient to rebut the presumption of regularity. Id. Rather, the veteran bears the burden of producing clear evidence that VA did not follow its regular mailing practices or that its practices were not regular. Clarke v. Nicholson, 21 Vet. App. 130 (2006). Once the presumption of regularity has been rebutted, the burden shifts to VA to show that regular mailing practices were followed in mailing the document in question in accordance with applicable laws and regulations, or that the appellant actually received the notice. Crain v. Principi, 17 Vet. App. 182, 186 (2003). A review of the evidence of record reveals that the RO mailed the February 1997 rating decision to the Veteran's known address at that time. See February 21, 1997 notification letter. There is no record of VA receiving any "undeliverable notices" or "returned mail" from the Veteran's address. The Veteran's unsubstantiated assertion that he did not receive notice of the February 1997 rating decision, given these facts, is found to be not credible. Therefore, VA fulfilled its duty to notify the Veteran, and the February 1997 rating decision, as noted above, became final. Generally, when a claim is disallowed, it may not be reopened and allowed, and a claim based on the same factual basis may not be considered. Id. A claim on which there is a final decision may be reopened if new and material evidence is submitted. 38 U.S.C.A. § 5108. "New" evidence means existing evidence not previously submitted to agency decision makers. "Material" evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. In determining whether evidence is new and material, the "credibility of the evidence is to be presumed." Justus v. Principi, 3 Vet. App. 510, 513 (1992). The evidence of record at the time of the February 1997 rating decision included service treatment records, VA treatment records from February 1995 to September 1996, and the November 1996 and December 1996 VA examinations. Evidence received since the February 1997 rating decision includes, VA treatment records from August 2011 to August 2014, VA examination reports dated in September 2010 and June 2011, the hospital file from the VA Medical Center in Little Rock dated from October 1971 to February 1975, and from February 1991 to October 2010, the January 2015 Board hearing transcript, the Veteran's statements, and statements from his wife. Upon review of the evidence of record received since the February 1997 rating decision, the Board finds that new and material evidence has been received to reopen service connection for tinea cruris. During the January 2015 Board hearing, the Veteran testified that he had a rash on his groin in service and he was given cream while in the field in order to alleviate symptoms. The Board finds that this evidence is new, as it was not of record prior to the issuance of the February 1997 rating decision. The aforementioned evidence, moreover, is material within the meaning of applicable law and regulations because it is probative of the issue at hand, which is whether the Veteran's tinea cruris first manifested in service and was incurred in service. As noted above, in determining whether evidence is new and material, the "credibility of the evidence is to be presumed." Justus, 3 Vet. App. 510. The Board further finds that new and material evidence has been received to reopen service connection for numbness and weakness of the left lower extremity. During the January 2015 Board hearing, the Veteran testified that his left lower extremity numbness and weakness is related to his service-connected coronary artery disease bypass grafting. Specifically, the Veteran stated that the procedure included taking "a vein out of my leg." The Board finds that this evidence is new, as it was not of record prior to the issuance of the February 1997 rating decision. The aforementioned evidence is also material because it is probative of the issue at hand, which is whether the Veteran's left lower extremity disorder is related to a now service-connected disability (i.e., coronary artery disease). In regard to the claims to reopen service connection for breathing problems, esophagus problems, enlarged liver, and urinary problems the Board notes that the RO found that the claims were reopened based on the Veteran's assertions of a link between his breathing problems, esophagus problems, enlarged liver, and urinary problems and his service-connected mandible disability or mediations prescribed for his disabilities. See May 2014 statement of the case. The Board finds that new and material evidence has been submitted to reopen the claims. In his claim to reopen service connection for breathing problems and esophagus problems, and during the January 2015 Board hearing, the Veteran stated that his breathing problems and esophagus problems began after he was shot in the mandible. The Veteran also now has diagnoses of allergic rhinitis and GERD. As to the liver disorder and urinary disorder, the Veteran testified that, as a result of his medication for his mandible disability, he has developed liver and urinary disorders. The Board finds that this evidence is new, as it was not of record prior to the issuance of the February 1997 rating decision. The Board finds that this evidence is material within the meaning of applicable law and regulations because it is probative of the issue at hand, which is whether the Veteran's breathing, esophagus, liver, and urinary problems are related to a service-connected disability. Thus, the Board finds that the newly added evidence relates to an unestablished fact necessary to substantiate the Veteran's claims of service connection for tinea cruris, numbness and weakness of the left lower extremity, breathing problems, esophagus problems, enlarged liver, and urinary disorders. 38 C.F.R. § 3.156(a). Accordingly, the Veteran's claims of service connection for tinea cruris, numbness and weakness of the left lower extremity, breathing problems, esophagus problems, enlarged liver, and urinary problems are reopened. The Board finds that it may proceed with the adjudication of the claims for service for a liver disorder on the merits without prejudice to the Veteran. The RO has provided the Veteran notice as to the requirements for service connection. The Veteran has presented evidence and argument throughout the instant appeal addressing the merits of service connection for this disability. The August 2011 rating decision addressed the merits of the issue, and the May 2014 statement of the case provided a discussion of the merits of the issue. For these reasons, the Board finds no prejudice to the Veteran to address the issue of entitlement to service connection for a liver disorder on a de novo basis. Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The condition of an enlarged liver is not a "chronic disease" listed under 38 C.F.R. § 3.309(a) (2014); therefore, the presumptive service connection provision of 38 C.F.R. § 3.303(b) do not apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The U.S. Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). In rendering a (merits) decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment, including by a veteran. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner's opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Service Connection for a Liver Disorder During the January 2015 Board hearing, the Veteran testified that he had been previously told that he had an enlarged liver. The Veteran maintains that this disorder is due to the medication he is taking for his other disabilities or as a result of his exposure to Agent Orange in service. See Board Hearing Transcript at pg. 22. As noted above, the existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that section 1110 of the statute requires the existence of a present disability for VA compensation purposes); see also, Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). See also McClain v. Nicholson, 21 Vet. App. 319 (2007) (holding that the requirement that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even if the disability resolves prior to the adjudication of the claim.). Here, the Board finds that although the Veteran claims that he has a liver disorder deriving from service or as a result of medications from his service-connected disabilities, the competent and probative evidence of record does not establish the presence of an actual diagnosed liver disorder. The Board finds that clinical findings of an enlarged liver is not in and of itself a disability for VA purposes. A laboratory finding is an indication of an injury or disease which could result in disability rather than a disability in and of itself. See 61 Fed. Reg. 20,440 (May 7, 1996) (discussing hyperlipidemia, elevated triglycerides, and elevated cholesterol). Essentially, an enlarged liver is not, in and of itself, a disability for VA purposes, nor has it been identified as a primary manifestation of any diagnosed liver disorder. Moreover, the evidence does not demonstrate an actual diagnosis of an enlarged liver. In a September 2010 VA examination report, the Veteran stated that he had been told that he had an enlarged liver approximately 10 years prior; however, the VA examiner noted that a 1997 ultrasound showed a normal size liver. Further, the September 2010 VA examiner performed an abdominal ultrasound and noted that the liver was of normal size and echo texture, without focal mass identified. As such, the examiner did not provide a diagnosis related to a liver disorder. Further, a review of VA treatment records does not show a diagnosis relating to the Veteran's liver. The Board has also reviewed and considered the lay statements and testimony in support of the Veteran's claim. However, the Board finds that he is not competent to render a diagnosis of a liver disorder which requires a medical professional with sufficient training and expertise. See 38 C.F.R. § 3.159(a)(1)-(2); see also Jandreau, 492 F.3d at 1377 (describing situations when lay evidence can be competent and sufficient to provide medical diagnosis). In this regard, an enlarged liver is a process that is confirmed by laboratory tests (such as an ultrasound) and not one that is capable of lay observation. As such, the Veteran is not competent to say, by way of diagnosis, whether he has any liver disorder or liver disease. As the Veteran is not competent to provide lay evidence of a current diagnosis, his lay statements regarding diagnosis are not probative in this case. See Layno, 6 Vet. App. at 465 (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). Congress specifically limits entitlement to service connection for disease or injury to cases where such results in disability. In the absence of proof of current disability due to in-service disease or injury, there can be no valid claim. See Brammer at 225. For these reasons, the Board finds that the Veteran has not met the essential requirement of showing evidence of a current disability involving the liver; the preponderance of the evidence is against his claim. As such, the reasonable doubt doctrine is not for application, and the claim for service connection for a liver disorder must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for an tinea cruris is reopened. Service connection for numbness and weakness of the left lower extremity is reopened. Service connection for breathing problems is reopened. Service connection for esophageal problems is reopened. Service connection for urinary problems is reopened. Service connection for an enlarged liver disorder is reopened. Service connection for a liver disorder (claimed as an enlarged liver) is denied. (CONTINUED ON NEXT PAGE) REMAND Tinea Cruris During the January 2015 Board hearing, the Veteran testified that he developed a rash on his groin while in the field due to crawling around in wet terrains and in buffalo manure. He further testified that he was given cream while in the field in order to alleviate his symptoms. The Veteran served in Vietnam and was awarded, in pertinent part, a combat infantry badge. See DD Form 214. Accordingly, the Board recognizes that he had combat service in Vietnam. In Collette v. Brown, 82 F.3d 389 (Fed. Cir. 1996), the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that under 38 U.S.C.A. § 1154(b), a combat veteran's assertions of an event during combat are to be presumed if consistent with the time, place and circumstances of such service. Here, the Veteran testified that he developed a rash on his groin while in the field due to crawling around in wet terrains and in buffalo manure. He further testified that he was given cream while in the field in order to alleviate symptoms. As the Veteran's reports are consistent with the time, place, and circumstances of his service, such an incident is presumed to have occurred. The Veteran has not been afforded a VA examination in order to assist in determining whether his in-service rash was the first manifestation of tinea cruris or whether tinea cruris is related to service. As such, the Board finds that a VA examination is warranted. Numbness and Weakness of the Left Lower Extremity During the January 2015 Board hearing, the Veteran testified that his left lower extremity numbness and weakness is related to his service-connected coronary artery disease bypass grafting. Specifically, the Veteran stated that the bypass grafting procedure included taking "a vein out of my leg." The Board notes that the Veteran was granted service connection for coronary artery bypass graft with coronary artery disease in a November 2014 rating decision. The Veteran was afforded a VA examination to determine whether his left lower extremity disorder was related to his back surgery (which is not a service-connected disability). See June 2011 VA examination. The Veteran, however, has not been afforded a VA examination to ascertain whether his left lower extremity disorder is caused or aggravated by the service-connected coronary artery disease disability. As such, a remand is warranted. Breathing Problems (Allergic Rhinitis) In a September 2010 VA examination report, the Veteran reported shortness of breath "for a long time." The VA examiner conducted a physical examination, reviewed the evidence of record, and diagnosed the Veteran with allergic rhinitis. The examiner then opined that "it is less likely that the jaw injury would lead to lung or heart problems. He is being treated for allergic rhinitis and reports difficulty breathing through the nose, and this is less likely due to the jaw injury." Although the September 2010 VA examiner provided an opinion as to whether the Veteran's breathing problems, to include allergic rhinitis, were caused by the service-connected mandible disability, a rationale for the opinion was not provided. Further, an opinion as to whether the Veteran's breathing problems and allergic rhinitis are aggravation by the service-connected mandible disability was not rendered. As such, the Board finds that a supplemental VA medical opinion should be obtained. Esophagus Problems (GERD) In the September 2010 VA examination report, the Veteran stated that he was on certain medications in the past for allergies and itching and apparently they were producing gastrointestinal side effects. These medications were noted to have been discontinued, and the Veteran reported that they had triggering reflux symptoms. The Veteran also noted that he had heartburn every day and also nausea after taking his medications. He reported having "burning" in his stomach and belching. The examiner diagnosed the Veteran with GERD and opined that it was "less likely due to his jaw injury; however, he has difficulty chewing secondary to the residuals of the jaw injury which would be contributing to his dysphagia." Also, the examiner noted that the Veteran was "likely" experiencing some gastrointestinal side effects from his medications. Although the examiner provided an opinion as to whether the Veteran's GERD disability was caused by the service-connected mandible disability, a rationale for the opinion was not provided. Further, an opinion as to whether the Veteran's GERD was aggravated by the service-connected mandible disability was not rendered. As such, the Board finds that a supplemental VA medical opinion should be obtained. Urinary Problems During the September 2010 VA examination, the Veteran reported having recurrent urinary tract infections since his return from Vietnam. He also noted that he had been treated for prostatitis in the past and reported being told that he had an enlarged prostate. The examiner diagnosed the Veteran, in pertinent part, with benign prostatic hypertrophy, recurrent urinary tract infections, and chronic prostatitis. The examiner then opined that the Veteran's service-connected mandible disability and associated medications (tramadol and acetaminophen) were "less likely to lead to prostate problems or recurrent urinary tract infections or prostatitis." The examiner, however, did not provide a rationale for the opinion and did not address whether the Veteran's urinary disorders, diagnosed as benign prostatic hypertrophy, recurrent urinary tract infections, and chronic prostatitis were aggravated by the service-connected mandible disability, to include medications prescribed for the mandible disability. Accordingly, a supplemental medical opinion is warranted. Lipoma During the January 2015 Board hearing, the Veteran testified that he had lipomas on his shoulder "about a year after" he was discharged from service. The Veteran stated that he sought treatment at that time. Although it appears that the Veteran testified as to the name of the physician who treated him for lipoma, the transcript notes that the doctor's name was (inaudible). Accordingly, on remand, the Veteran should be asked to provide the name and location of the physician who treated him approximately one year after service. Then, attempts should be made to obtain those records. The Veteran also should be afforded a VA examination to assist in determining the etiology of his lipomas, to include whether they are due to in-service herbicide exposure. Combee v. Brown, 24 F.3d 1039, 1043-44 (Fed. Cir. 1994). SMC Based on the Need for Aid and Attendance or at the housebound rate The outcome of the aforementioned issues may affect the Veteran's claims for SMC based on the need for aid and attendance or at the housebound rate. Thus, the latter issues are inextricably intertwined with the Veteran's claims remanded herein. See Harris v. Derwinski, 1 Vet. App. 180 (1991) and are deferred pending the readjudication of such issues. Manlicon Issues In a November 2014 rating decision, the RO adjudicated the following issues: (1) granted service connection and assigned an initial rating of 10 percent for coronary artery bypass graft with coronary artery disease beginning November 1, 2013; (2) granted service connection and assigned an initial rating of 10 percent for epiphora left eye; (3) granted service connection and assigned a 10 percent rating for postoperative coronary artery bypass graft scar; (4) granted service connection and assigned a zero percent rating for bilateral hearing loss; (5) denied an increased rating in excess of 20 percent for residuals, gunshot wound of mandible; (6) denied an increased rating in excess of 10 percent for residuals, gunshot wound of 5th cranial nerve; (7) denied a compensable rating for donor site, left iliac crest; (8) denied service connection for renal cell carcinoma (claimed as kidney disease); (9) denied service connection for degenerative speech; (10) denied service connection for bilateral cataracts (also claimed as blurred and double vision); (11) denied service connection for hernia; and (12) denied service connection for diabetes mellitus type II associated with Agent Orange. In December 2014, the Veteran filed a notice of disagreement with the RO's findings regarding the issues listed above. Accordingly, a Statement of the Case must be sent to the Veteran on these issues. See Manlicon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Obtain any outstanding VA treatment notes not currently of record and associate them with the electronic claims file. 2. Ask the Veteran to clarify the name and location of the doctor where he first received treatment for his lipoma. The Veteran should be asked to provide an authorization for release of the medical records to VA. If the Veteran provides information and authorization, make an initial request for the applicable records with a follow-up request or requests as necessary. Associate all records received with the paper or electronic claims file. If requested treatment records are not received, notify the Veteran and his representative pursuant to established procedure. 3. Schedule the Veteran for an appropriate VA examination to assist in determining the etiology of his lipoma disorder. Any indicated tests should be accomplished. The examiner should review the claims file prior to examination, to include any newly associated records obtained as a result of this remand. Then, the examiner is asked to provide an opinion as to the following: Is it at least as likely as not (50 percent or more probability) that the Veteran's lipoma condition was incurred in service or is otherwise related to service? The examiner should assume that the Veteran was exposed to Agent Orange during service. All opinions are to be accompanied by a rationale consistent with the evidence of record. 4. Schedule the Veteran for an appropriate VA examination to assist in determining the etiology of his tinea cruris disorder. Any indicated tests should be accomplished. The examiner should review the claims file prior to examination, to include any newly associated records obtained as a result of this remand. Then, the examiner is asked to provide an opinion as to the following: Is it at least as likely as not (50 percent or more probability) that the Veteran's current tinea cruris condition was incurred in service or is otherwise related to service? The examiner should assume that the Veteran was exposed to Agent Orange during service and that he was given cream while in the field in order to alleviate symptoms associated with a rash on his groin. All opinions are to be accompanied by a rationale consistent with the evidence of record. 5. Schedule the Veteran for an appropriate VA examination to assist in determining the etiology of his left lower extremity disorder. Any indicated tests should be accomplished. The examiner should review the claims file prior to examination, to include any newly associated records obtained as a result of this remand. Then, the examiner is asked to provide an opinion as to the following: (a) List all diagnoses related to the Veteran's left lower extremity. (b) Is it as least as likely as not (i.e., 50 percent or greater probability) that the Veteran's left lower extremity disorder (claimed as weakness and numbness) is caused or aggravated ( permanently worsened) by the service-connected coronary artery disease disability? If aggravation is found, to the extent that is possible, the examiner is requested to provide an opinion as to approximate baseline level of severity of the nonservice-connected disorder before the onset of aggravation. All opinions are to be accompanied by a rationale consistent with the evidence of record. 6. The RO/AMC should obtain a supplemental medical opinion from the examiner who conducted the September 2010 VA examination regarding the Veteran's allergic rhinitis, GERD, and urinary disorder. If that examiner is not available, obtain an opinion from another appropriate VA examiner. If the examiner determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled; however, the Veteran should not be required to report for another examination if it is not found to be necessary. The entire record must be made available to and reviewed by the examiner. The VA examiner should offer the following opinions: (a) Is it as least as likely as not (i.e., 50 percent or greater probability) that the Veteran's breathing problem (allergic rhinitis) is caused or aggravated (permanently worsened) by the service-connected mandible disability? (b) Is it as least as likely as not (i.e., 50 percent or greater probability) that the Veteran's esophagus problems (GERD) is caused or aggravated by the service-connected mandible disability? If aggravation is found, to the extent that is possible, the examiner is requested to provide an opinion as to approximate baseline level of severity of the nonservice-connected disorder before the onset of aggravation. (c) Is it as least as likely as not (i.e., 50 percent or greater probability) that the Veteran's urinary problems (diagnosed as benign prostatic hypertrophy, recurrent urinary tract infections, and chronic prostatitis) are caused or aggravated (permanently worsened) by the service-connected mandible disability, to include medications prescribed for the disability? If aggravation is found, to the extent that is possible, the examiner is requested to provide an opinion as to approximate baseline level of severity of the nonservice-connected disorder before the onset of aggravation. All opinions are to be accompanied by a rationale consistent with the evidence of record. 7. Schedule the Veteran for an appropriate VA examination to assist in determining whether the Veteran's service-connected disabilities render him in need of regular aid and attendance from another person. Any indicated tests should be accomplished. The examiner should review the claims file prior to examination, to include any newly associated records obtained as a result of this remand. The examiner should answer the following: Do the Veteran's service-connected disabilities render him unable to or in need of assistance to dress or undress himself, keep himself ordinarily clean and presentable, feed himself, attend to the wants of nature, or protect himself from the hazards or dangers incident to his daily environment? All opinions are to be accompanied by a rationale consistent with the evidence of record. 8. Issue a Statement of the Case on the issues of (1) an initial rating in excess of 10 percent for coronary artery bypass graft with coronary artery disease beginning November 1, 2013; (2) an initial rating in excess of 10 percent for epiphora left eye; (3) an initial rating in excess of 10 percent for postoperative coronary artery bypass graft scar; (4) an initial compensable rating for bilateral hearing loss; (5) an increased rating in excess of 20 percent for f residuals, gunshot wound of mandible; (6) an increased rating in excess of 10 percent for residuals, gunshot wound of 5th cranial nerve; (7) a compensable rating for donor site, left iliac crest; (8) service connection for renal cell carcinoma (claimed as kidney disease); (9) service connection for degenerative speech; (10) service connection for bilateral cataracts (also claimed as blurred and double vision); (11) service connection for hernia; and (12) service connection for diabetes mellitus type II associated with Agent Orange. Only if the Veteran perfects an appeal should the claims be certified to the Board. 9. After all the above development has been completed, readjudicate the remaining claims on appeal in light of all of the evidence of record, as well as any evidence added pursuant to this Remand. If the benefits sought remain denied, the Veteran and his representative should be provided with a supplemental statement of the case and afforded a reasonable period of time within which to respond. 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 2014). ______________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs