Citation Nr: 1522323 Decision Date: 05/27/15 Archive Date: 06/11/15 DOCKET NO. 10-21 095 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a heart disorder, to include coronary artery disease and ischemic heart disease. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for diabetes mellitus. 4. Entitlement to service connection for hepatitis C. 5. Entitlement to service connection for liver disease. 6. Entitlement to service connection for neuropathy. 7. Entitlement to service connection for skin cancer. 8. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for posttraumatic stress disorder (PTSD). 9. Entitlement to service connection for an acquired psychiatric disorder, to include depression, PTSD and bipolar disorder. 10. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for a lumbar spine disability and, if so whether service connection is warranted. 11. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for residuals of shrapnel fragment wounds to the back, buttocks, and legs and, if so whether service connection is warranted. 12. Entitlement to an increased rating for an appendectomy scar, currently evaluated as 10 percent disabling. 13. Entitlement to a total rating based on unemployability due to service-connected disability (TDIU). 14. Entitlement to an effective date earlier than March 19, 2009 for the grant of a 10 percent disability rating for the appendectomy scar. REPRESENTATION Appellant represented by: Kenneth L. LaVan, Attorney at Law WITNESSES AT HEARING ON APPEAL Appellant, R.D., and B.S. ATTORNEY FOR THE BOARD J. Barone, Counsel INTRODUCTION The Veteran had active service from May 1968 to May 1970. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. A February 2009 rating decision declined to reopen a claim of entitlement to service connection for a lumbar spine disability, reopened a claim of entitlement to service connection for PTSD, and denied service connection for PTSD, depression, and bipolar disorder. The Veteran perfected an appeal with respect to these issues. A May 2009 rating decision denied a compensable rating for the appendectomy scar. By way of the January 2014 statement of the case, the RO determined that the attorney's notice of disagreement was timely filed. The Veteran thereafter perfected an appeal with respect to the issue. A January 2014 rating decision increased the rating to 10 percent effective March 19, 2009. The RO determined in July 2009 that new and material evidence had not been submitted to reopen a claim of entitlement to service connection for shrapnel fragment wounds. The Veteran perfected an appeal. An October 2011 rating decision denied service connection for diabetes mellitus, a heart condition, hypertension, hepatitis C, a liver disorder, neuropathy, and skin cancer; and granted a 10 percent evaluation for the Veteran's appendectomy scar. In a January 2014 statement of the case, the RO included the issue of a TDIU. The Veteran perfected an appeal with respect to all of these issues. The issues of entitlement to service connection for a heart disorder, hypertension, diabetes mellitus, hepatitis C, a liver disorder, neuropathy, skin cancer, an acquired psychiatric disorder, a lumbar spine disability, residuals of shrapnel fragment wounds; an increased rating for an appendectomy scar; TDIU; and entitlement to an earlier effective date for the grant of a 10 percent disability rating for the appendectomy scar are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. In a January 2003 rating decision, the RO denied service connection for PTSD; the Veteran did not appeal. 2. The evidence received since the January 2003 rating decision is not cumulative or redundant of evidence previously of record, relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for PTSD, and raises a reasonable possibility of so substantiating the claim. 3. In a May 1989 rating decision, the RO denied service connection for a back disability; in a January 2003 rating decision, the RO declined to reopen the claim; the Veteran did not appeal. 4. The evidence received since the January 2003 rating decision is not cumulative or redundant of evidence previously of record, relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for a back disability, and raises a reasonable possibility of so substantiating the claim. 5. In a May 1989 rating decision, the RO denied service connection for residuals of shrapnel fragment wounds to the back, buttocks, and legs; the Veteran did not appeal. 6. The evidence received since the May 1989 rating decision is not cumulative or redundant of evidence previously of record, relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for shrapnel fragment wound residuals of the back, buttocks, and legs, and raises a reasonable possibility of so substantiating the claim. CONCLUSIONS OF LAW 1. The May 1989 and January 2003 rating decisions are final. 38 U.S.C.A. § 7104(b) (West 2014); 38 C.F.R. §§ 3.160(d), 20.1103 (2014). 2. New and material evidence has been received to reopen the claim of entitlement to service connection for PTSD, a back disability and shrapnel fragment wounds of the back, buttocks and legs. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2014). Because the Board has determined that new and material evidence has been received sufficient to reopen the claims of entitlement to service connection for PTSD, a lumbar spine disability, and shrapnel fragment wounds, no further discussion of the VCAA is necessary at this time. Analysis Entitlement to VA compensation may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. §§ 1110 (wartime service), 1131 (peacetime service); 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, a claimant must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Generally, a claim which has been denied in an unappealed RO decision or an unappealed Board decision may not thereafter be reopened and allowed. 38 U.S.C.A. §§ 7104(b), 7105(c) (West 2014). The exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decisionmakers. 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). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). But see Duran v. Brown, 7 Vet. App. 216 (1994) ("Justus does not require the Secretary [of VA] to consider the patently incredible to be credible"). PTSD Service connection for PTSD was denied in a January 2003 rating decision. The RO noted that while the Veteran's reported stressor was being shot in Puerto Rico in 1969, there was no evidence of that incident. As there was no evidence supporting the Veteran's reported stressor, service connection was denied. The Veteran did not appeal and new and material evidence was not received within one year of the rating decision. The decision is, therefore, final. The evidence of record at the time of the January 2003 rating decision included the Veteran's assertion that he had been shot in the back while on Vieques, Puerto Rico, during the summer of 1969. The record also contained the Veteran's service treatment records. They are negative for a diagnosis of PTSD; however, the Veteran did complain of harassment in February 1969 and was assessed with immature passive dependent personality. The service treatment records do not contain any reference to treatment for shrapnel fragment or gunshot wounds. The separation physical examination in May 1970 was negative for psychiatric abnormality. As discussed, service connection for PTSD was denied in 2003 because there was no evidence of a confirmed stressor upon which a diagnosis of PTSD was based. Since the January 2003 rating decision, evidence added to the record includes statements by the Veteran's siblings describing their memories of their parents being notified telephonically that the Veteran had been shot while he was in the Marine Corps. Because there is new evidence supportive of the Veteran's contention that he was shot during service, and this cures a defect that was previously identified by the AOJ, the Board concludes that the claim of entitlement to service connection for PTSD may be reopened. The reopened claim is addressed in the remand below. Back Disability and Shrapnel Fragment Wounds A May 1989 rating decision denied service connection for a back disability and shrapnel fragment wounds. The RO noted that service treatment records revealed no diagnosis or treatment for back pain, and that there was no indication of shrapnel fragment wounds during service. In January 2003, the RO declined to reopen the claim of entitlement to service connection for a back disability. At the time of these prior rating decisions, the record contained the Veteran's service treatment records. They are negative for any diagnosis, complaint, or abnormal finding suggestive of a back disability, and do not reflect treatment for shrapnel fragment wounds. The record also contained the Veteran's contentions that he was injured by a gunshot during service and that he underwent treatment and had residuals of that injury. As discussed, the RO denied the Veteran's claims on the basis that there was no evidence of an injury during service. Since the prior final rating decisions, evidence added to the record includes statements by the Veteran's siblings describing their memories of their parents being notified telephonically that the Veteran had been shot while he was in the Marine Corps. Because there is new evidence supportive of the Veteran's contention that he was shot during service, and this cures a defect that was previously identified by the AOJ, the Board concludes that the claims of entitlement to service connection for a back disability and shrapnel fragment wounds may be reopened. The reopened claims are addressed in the remand below. ORDER New and material evidence having been submitted, the claim of entitlement to service connection for PTSD is reopened. New and material evidence having been submitted, the claim of entitlement to service connection for a lumbar spine disability is reopened. New and material evidence having been submitted, the claim of entitlement to service connection for shrapnel fragment wounds of the back, buttocks, and legs is reopened. REMAND As an initial matter, the Board notes that upon review of the record, it appears that various medical records remain outstanding. In a May 2002 VA Form 21-4142, the Veteran identified treatment at the Columbia, South Carolina VA Medical Center (VAMC) in 1989. The Board additionally notes that during an examination for Social Security Administration (SSA) purposes in November 2001, the Veteran reported that he had attempted suicide in 1986 and was hospitalized for 90 days. On VA examination in March 1989, the Veteran reported that he had been treated in Macon, Georgia in 1987 for myocardial infarction, and at Richland Memorial Hospital in Novebmer 1988 for a second myocardial infarction. On SSA examination in January 2002, the Veteran reported three myocardial infarctions beginning in 1986, and that he had undergone coronary artery bypass graft in 1997. The Veteran has also reported that he was diagnosed with hepatitis C at Jackson Memorial Hospital in 2002. He also had reported during the March 1989 VA examination that he was hospitalized for 7 days in 1971 for hepatitis. There is no indication that records pertaining to these episodes of treatment have been sought. As records of this treatment are relevant to the Veteran's appeal, they should be obtained, if possible. The Veteran asserts that he was injured by a gunshot wound during service, and that he has residuals of that injury, to include shrapnel fragment wounds, a back disability, and PTSD. On X-ray examination in March 1989, the radiologist identified several small metallic densities projected over the region of the greater trochanter of the proximal left femur. The assessment was history of minor shrapnel wounds of the left buttocks. The examiner did not provide any opinion with respect to the source of the metallic densities found on X-ray examination. As the Veteran's claim with respect to the issues of entitlement to service connection for shrapnel fragment wounds, a back disability, and PTSD essentially turns on the claimed in-service gunshot wound, the Board concludes that a VA examination is necessary to determine whether the metallic densities found on examination in 1989 are of the sort that might be present as the result of the incident described by the Veteran. The Veteran seeks service connection for various disabilities which he asserts are related to contaminated drinking water at Camp Lejeune. During his October 2014 hearing, his attorney asserted that heart disease, hypertension, diabetes, hepatitis C, liver disease, neuropathy, and skin cancer were related to his exposure to the drinking water at Camp Lejeune. With regard to veterans who served at Camp Lejeune between 1957 and 1987, VA has recognized potential exposure to contaminants present in the base water supply prior to 1987. Veterans Benefits Administration (VBA) Training Letter 10-03 (April 26, 2010). For background purposes, in the early 1980s, it was discovered that two on-base water-supply systems were contaminated with the volatile organic compounds (VOCs) trichloroethylene (TCE), a metal degreaser, and perchloroethylene (PCE), a dry cleaning agent. The main source of TCE contamination was on-base industrial activities, while the main source of PCE was an off-base dry cleaning facility. Benzene, vinyl chloride, and other VOCs were also found to be contaminating the water-supply systems. Those water systems served housing, administrative, and recreational facilities, and the base hospital. The Agency for Toxic Substances and Disease Registry a branch of the federal Department of Health and Human Services, conducted a Public Health Assessment of Camp Lejeune in 1997, which did not determine whether base personnel experienced any long-term health effects from consumption of the contaminated water. However, the assessment indicated that the drinking water contaminants at Camp Lejeune created a past public health hazard. Recent studies have been conducted involving the National Academy of Sciences' National Research Council and the Agency for Toxic Substances and Disease Registry. Based on a congressional mandate, the Department of the Navy requested that the National Research Council undertake a study to assess the potential long-term health effects for individuals who served at Camp Lejeune during the period of water contamination. In the resulting report, Contaminated Water Supplies at Camp Lejeune, Assessing Potential Health Effects (June 2009), the National Research Council reviewed previous work done by the Agency for Toxic Substances and Disease Registry, including computerized water flow modeling, and concluded that additional studies may not produce definitive results because of the difficulties inherent in attempting to reconstruct past events and determine the amount of exposure experienced by any given individual. To address potential long-term health effects, the National Research Council focused on diseases associated with TCE, PCE, and other VOCs. Based on analyses of scientific studies involving these chemicals, the National Research Council provided an assessment of the potential association between certain diseases and exposure to the chemical contaminants. The National Research Council analysis used categories of potential disease 'health outcomes.' The categories included: (1) sufficient evidence of a causal relationship; (2) sufficient evidence of an association; (3) limited/suggestive evidence of an association; (4) inadequate/insufficient evidence to determine whether an association exists; and (5) limited suggestive evidence of no association. The analysis found that no diseases fell into the categories of sufficient evidence of a causal relationship or sufficient evidence of an association with the chemical contaminants. However, fourteen diseases were placed into the category of limited/suggestive evidence of an association. According to VBA Training Letter 11-03 (April 27, 2011), the Agency for Toxic Substances and Disease Registry, in a 2010 letter to the Department of the Navy, indicated its belief that the National Research Council report minimized the potential long-term health effects of exposure to the water contamination. The letter stated the view that 'there was undoubtedly a hazard associated with drinking the contaminated water at Camp Lejeune.' The Agency for Toxic Substances and Disease Registry noted that, although the National Research Council report found only limited/suggestive evidence for any diseases associated with the contaminated water, other scientific organizations considered the contaminants to be carcinogenic. For example, regarding TCE and PCE, the International Agency for Research on Cancer classifies them as 'probable human carcinogens' while the National Toxicology Program refers to them as 'reasonably anticipated to be a human carcinogen.' Additionally, both the International Agency for Research on Cancer and the National Toxicology Program label benzene and vinyl chloride as 'known human carcinogens.' Although the Agency for Toxic Substances and Disease Registry letter emphasizes the fact that the water contaminants themselves have been generally associated with potential carcinogenic health outcomes in humans, there is currently only speculation as to the extent of exposure and actual effects on the population at Camp Lejeune. However, the Agency for Toxic Substances and Disease Registry indicated that its planned studies, making use of computerized water flow modeling and the epidemiological mortality and health survey, will provide a higher level of exposure predictability and definable health outcomes than are recognized as possible by the National Research Council. According to Training Letter 11-03, scientific organizations, including the National Research Council and the Agency for Toxic Substances and Disease Registry, have determined that some evidence is available that suggests a possible association between development of certain diseases and exposure to the chemicals known to have contaminated the water at Camp Lejeune. To date, there are no definitive scientific studies that can provide conclusive evidence that an individual who served at Camp Lejeune during the period of water contamination developed a particular disease as a result of that service. Therefore, until scientific evidence shows otherwise, it will be assumed by VA that any Veteran who served at Camp Lejeune was potentially exposed in some manner to the full range of chemicals known to have contaminated the water there between 1957 and 1987. The record confirms that the Veteran was present at Camp Lejeune during this period. Service connection for any disability claimed to have resulted from contaminated water exposure at Camp Lejeune requires sufficient medical evidence that the disability is related to that exposure. That medical evidence will generally come from a competent and qualified medical examiner that provides an opinion establishing a rational nexus or link between the claimed disability and the exposure. Some diseases have been scientifically associated to a greater or lesser extent with exposure to the chemical contaminants in the water at Camp Lejeune. However, that does not mean that service connection can automatically be established for a Camp Lejeune Veteran claiming one of these diseases. It is up to a competent medical authority, based on each Veteran's individual case, to determine whether it is at least as likely as not that the claimed disease or disability has resulted from the contaminant exposure at Camp Lejeune. Sufficient medical evidence to establish the required nexus may come from a private physician or other competent private medical authority. A medical opinion should be requested when a claim: (1) contains competent lay or medical evidence of a current diagnosed disability or persistent or recurrent symptoms of disability; (2) establishes that the veteran suffered an event, injury, or disease in service; and (3) indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service. 38 C.F.R. § 3.159(c)(4) (2012). Those requirements establish a relatively low threshold for requesting medical examinations for Camp Lejeune Veterans. The first requirement is met when a claimant provides any credible lay or medical evidence showing a current diagnosis or symptoms of a disease or disability. The second is met when service at Camp Lejeune between 1957 and 1987 is verified. The third is met when the claimed disease or disability is one that can reasonably be associated with the known water contaminants at Camp Lejeune. When medical opinions are requested, it should be kept in mind that the claims represent a unique situation for VA medical examiners. They must determine, on a case-by-case basis, whether a particular claimed condition is linked to contaminated water exposure. In order to assist them with their assessment and determination, the RO must provide them with the following Appendices to VBA Training Letter 11-03. That information replaces the Camp Lejeune "Fact Sheet" intended for VA examiners found in Training Letter 10-03. Appendix A, Internet websites related to the issue of contaminated water at Camp Lejeune. Appendix B, Diseases potentially associated with exposure to contaminants present in the Camp Lejeune water supply between 1957 and 1987. Appendix C, Websites describing potential health effects of exposure to chemical contaminants present in the water supply of Camp Lejeune between 1957 and 1987, and Appendix D, Notice to Examiners Evaluating Claims Based on Service at Camp Lejeune. That information is intended to provide the examiners with an adequate basis for providing a reasoned opinion which is a critical element for evaluating the claim. Appendix B of VBA Training Letter 11-03 provides a list of diseases potentially associated with exposure to contaminants present in the Camp Lejeune water supply between 1957 and 1987 based on the publication by NRC of its Contaminated Water Supplies at Camp Lejeune, Assessing Potential Health Effects, in 2009. This report includes a review of studies addressing exposure to TCE, and PCE, and a mixture of the two, and a discussion of disease manifestations potentially associated with such exposure. Therefore, the Board finds that a medical opinion is necessary to determine the etiology and relationship, if any, between the claimed heart disease, hypertension, diabetes, hepatitis C, liver disease, neuropathy, and skin cancer and the Veteran's period of active service, to include as a result of exposure to contaminated drinking water at Camp Lejeune. During his October 2014 hearing, the Veteran described symptoms associated with his service-connected appendectomy scar. He related that he felt pressure under the scar, as if there was a lump under his skin. His attorney asserted that the scar was unstable. The Veteran's service-connected appendectomy scar has not been examined for compensation purposes since August 2011. In light of his current complaints, the Board concludes that a current examination is warranted. Because the development outlined in this remand might produce evidence supportive of the Veteran's claim for a TDIU, the Board has concluded that it would be inappropriate at this juncture to enter a final determination on this issue. See Henderson v. West, 12 Vet. App. 11 (1998), citing Harris v. Derwinski, 1 Vet. App. 180 (1991), for the proposition that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any review of the decision on the other claim meaningless and a waste of appellate resources, the claims are inextricably intertwined. Although a notice of disagreement (NOD) was received with regard to the March 2014 rating decision which granted an earlier effective date to March 19, 2009 for the 10 percent rating for the appendectomy scar, a statement of the case (SOC) has not been issued. When an NOD has been filed with regard to an issue, and an SOC has not been issued, the appropriate Board action is to remand the issue to the agency of original jurisdiction for issuance of an SOC. Manlincon v. West, 12 Vet. App. 238 (1999). Thus a remand is required for issuance of an SOC and to provide the Veteran the opportunity to perfect an appeal. 38 U.S.C.A. § 7105; 38 C.F.R. § 19.26; See Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran identify any additional VA and non-VA medical records, not already associated with the claims file, that are relevant to his claim, to include records from all private practitioners whom he has seen for treatment of his claimed disabilities. He should be specifically asked to identify any private treatment for myocardial infarction since 1986 (to include but not limited to Collisum Hospital, Macon, GA; Richland Memorial, SC) and for hepatitis C (including but not limited to the hospital where he was hospitalized in 1971 in Broward County, FL, for 7 days and Jackson Memorial Hospital in 2002). He should also be asked to provide information concerning where he was hospitalized in 1986 for a suicide attempt. Request that the Veteran complete and return any necessary authorization forms. 2. Obtain all outstanding VA records, including those identified by the Veteran in response to step 1. This should include all records from the Miami VAMC, the Columbia VAMC, and the facility at Oakland Park, including any retired or archived records. 3. Again contact the National Personnel Records Center to request records of inpatient treatment, including clinical records, of the Veteran at Roosevelt Roads Hospital in Puerto Rico at any point in time between May 1968 and May 1970. All attempts to fulfill this development should be documented in the claims file. If after continued efforts to obtain the records it is concluded that it is reasonably certain they do not exist or further efforts to obtain them would be futile, notify the Veteran and (a) identify the specific records VA is unable to obtain; (b) briefly explain the efforts that VA made to obtain those records; (c) describe any further action to be taken by VA with respect to the claim; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 4. Thereafter, schedule the Veteran for a VA examination to determine whether he currently has retained metallic bodies in his back, buttocks or legs, and if so, their etiology. The claims folder should be forwarded to the examiner for review. The examiner should be directed to elicit a complete history from the Veteran. All indicated studies should be performed, and their results reported. Following review of the claims file and examination of the Veteran, the examiner should indicate whether the Veteran has any retained metallic bodies in his back, buttocks or legs that are of the type that result from gunshot or shrapnel fragment wounds. Any associated scars should be described. If the examiner identifies retained metallic bodies in the Veteran's back, buttocks, or legs, he should provide an opinion regarding whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent) such are related to an injury in service. The examiner's attention is directed to the lay statements from the Veteran and his family members concerning an injury in service. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. A discussion of the complete rationale for all opinions expressed should be included in the examination report, to include reference to the Veteran's lay statements and the private records. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 5. Following completion of the development outlined in paragraphs 1 to 3, schedule the Veteran for an examination to determine the etiology of the Veteran's claimed heart disease, hypertension, diabetes, hepatitis C, liver disease, neuropathy, and skin cancer, with consideration of his service at Camp Lejeune. The examiner must be provided access to the electronic claims file and a copy of VBA Fast Letter/Training Letter 11-03 with the four appendices, for review in conjunction with the examination. The examiner should be notified that the water supply at Camp Lejeune, North Carolina, was contaminated between 1957 and 1987 with a number of chemical compounds that have been associated by scientific organizations with the potential for developing certain diseases. Those include trichloroethylene (TCE), tetrachloroethylene, also known as perchloroethylene (PCE), benzene, and vinyl chloride. The Veteran served at Camp Lejeune during that period. The examiner should provide the following opinions: (a) Please opine whether it is at least as likely as not (50 percent or greater probability) that any heart disease, hypertension, diabetes, hepatitis C, liver disease, neuropathy, and skin cancer is related to the Veteran's exposure to contaminated water while serving at Camp Lejeune, and provide a rationale for that opinion. Information on how long the Veteran served at Camp Lejeune (see the Military Personnel Record on VBMS), and whether the Veteran lived on or off base, should be considered, if available. (b) Please opine as to whether it is at least as likely as not (50 percent or greater probability) that any heart disease, hypertension, diabetes, hepatitis C, liver disease, neuropathy, and skin cancer are otherwise related to the Veteran's service. 6. Upon completion of the development outlined in paragraphs 1 and 2, schedule the Veteran for a VA examination to determine the severity of his service-connected appendectomy scar. Any and all studies, tests and evaluations deemed necessary by the examiner should be performed. The examiner should also elicit a complete history from the Veteran, the pertinent details of which should be included in the examination report. Following examination of the Veteran and review of the claims file, the examiner should identify all currently present manifestations of the Veteran's appendectomy scar. 7. Review the examination reports to ensure that the questions posed by the Board are appropriately addressed. Any deficiency should be resolved prior to recertification to the Board. 8. Complete any additional development indicated, which may include examinations to determine the etiology of any back disability or acquired psychiatric disorder, if deemed appropriate. 9. Then readjudicate the claims, with application of all appropriate laws, regulations, and case law, and consideration of any additional information obtained as a result of this remand. If the decision remains adverse to the Veteran, he and his representative should be furnished a supplemental statement of the case and afforded an appropriate period of time within which to respond thereto. 10. Issue a SOC regarding the issue of entitlement to an earlier effective date than March 19, 2009 for the 10 percent rating for the appendectomy scar. Advise the Veteran of the procedural requirements to perfect an appeal of the issue. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ S. S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs