Citation Nr: 1543331 Decision Date: 10/08/15 Archive Date: 10/13/15 DOCKET NO. 12-34 000 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for ischemic heart disease, including as due to herbicide exposure. 2. Entitlement to service connection for strokes, including as secondary to ischemic heart disease. 3. Entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for skin cancer. REPRESENTATION Appellant represented by: Oklahoma Department of Veterans Affairs ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The Veteran served on active duty from September 1952 to August 1956, and from November 1956 to June 1973. He died in October 2013, and the appellant is his widow. She has been substituted as the appellant in this appeal in place of her late husband. 38 U.S.C.A. § 5121A (West 2014). This case comes to the Board of Veterans' Appeals (Board) partly on appeal from a July 2012 decision by the RO in Muskogee, Oklahoma that denied service connection for ischemic heart disease and strokes. This case also comes to the Board on appeal from a July 2010 RO decision that in pertinent part, denied service connection for bilateral hearing loss, skin cancer, and peripheral neuropathy. A notice of disagreement was received from the Veteran in September 2010 as to these issues, and a statement of the case was promulgated in June 2011. In an August 2011 VA Form 9 (substantive appeal), the Veteran stated that he only wanted to appeal the issues of hearing loss and skin cancer. He did not perfect an appeal of the issue of entitlement to service connection for peripheral neuropathy. Thus, the issue of service connection for peripheral neuropathy is not before the Board. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. § 20.200, 20.202, 20.302 (2015). A Board hearing was initially requested, but the appellant withdrew this request in March 2015. Additional evidence was received from the appellant in April 2015. As the appellant has waived initial RO review of this evidence, the Board will consider it. 38 C.F.R. § 20.1304 (2015). 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 entitlement to service connection for strokes, claimed as secondary to ischemic heart disease, and for skin cancer are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran had active service in Thailand during the Vietnam era; he did not serve in Vietnam, and is not shown to have set foot in Vietnam during the Vietnam era. 2. Resolving all doubt in the Veteran's favor, the Veteran is shown by competent, credible and persuasive evidence to have been exposed to herbicides in service at Nakhon Phanom Royal Thai Air Force Base (RTAFB) in Thailand. 3. The Veteran's diagnosed ischemic heart disease is presumed to be related to exposure to herbicide agents during his active military service in Thailand. 4. The competent and credible evidence of record shows that the Veteran's bilateral hearing loss began during active service. CONCLUSIONS OF LAW 1. The Veteran's ischemic heart disease is presumed to have been incurred in service. 38 U.S.C.A. §§ 1116, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2015). 2. The Veteran's bilateral hearing loss was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO provided the appellant pre-adjudication notice by letters dated in February 2010, October 2010, December 2010, and March 2012. The appellant has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful or prejudicial falls upon the party attacking the agency determination). VA also fulfilled its duty to assist the appellant by obtaining all relevant evidence in support of his claim, which is obtainable, and therefore appellate review may proceed without prejudicing her. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159 (2015); see also Bernard v. Brown, 4 Vet. App. 384 (1993). The Veteran and the appellant have submitted written statements in support of these claims. VA has obtained service treatment records (STRs), service personnel records, VA and private medical records, and assisted the appellant in obtaining evidence. All known and available records relevant to the issue on appeal have been obtained and associated with the appellant's claims file; and the appellant has not contended otherwise. Service Connection The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2014); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Service connection is granted if it is shown the Veteran suffers from disability resulting from an injury sustained or a disease contracted in the line of duty during active military service, or for aggravation during service of a pre-existing condition beyond its natural progression. 38 U.S.C.A. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303, 3.306. Other diseases initially diagnosed after service also may be service connected if the evidence, including that pertinent to service, shows the diseases were incurred in service. 38 C.F.R. § 3.303(d). Certain diseases like sensorineural hearing loss, as an organic disease of the nervous system, and cardiovascular-renal disease, including hypertension, are considered chronic, per se, and therefore will be presumed to have been incurred in or aggravated by service if manifested to a compensable degree (meaning to at least 10-percent disabling) within one year of separation from service. This presumption, however, is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic disease manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed. Cir. 2013) (holding that only conditions listed as chronic diseases in § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b)). In order to establish service connection for the claimed disorder, there must be (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, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303 (2014); see also Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). If a Veteran was exposed to certain herbicide agents during active military, naval, or air service, certain specified diseases, including ischemic heart disease, shall be presumptively service connected, if the requirements of 38 C.F.R. § 3.307(a) are met. 38 C.F.R. § 3.309(e) (2015). Governing regulation provides that ischemic heart disease includes, but is not limited to, acute, subacute, and old myocardial infarction, atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery, and stable, unstable and Prinzmetal's angina. Id. Diseases associated with exposure to certain herbicide agents used in support of military operations in the Republic of Vietnam during the Vietnam era will be presumed to have been incurred in service, even if there is no record of such disease during service. 38 U.S.C.A. § 1116(a)(1); 38 C.F.R. §§ 3.307(a)(6). This presumption requires exposure to an herbicide agent and manifestation of the disease to a degree of 10 percent or more within the time period specified for each disease. 38 C.F.R. § 3.307(a)(6)(ii). Furthermore, even if a Veteran does not have a disease listed at 38 C.F.R. § 3.309(e), it will be presumed that he was exposed to herbicides if he served in Vietnam between January 9, 1962 and May 7, 1975 (i.e., during the Vietnam era), unless there is affirmative evidence establishing he was not exposed to any such agent during that service. 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii); see also 38 C.F.R. § 3.313(a); Haas v. Peake, 525 F.3d 1168, 1197 (Fed. Cir. 2008), cert. denied, 129 S. Ct. 1002 (2009) (upholding VA's interpretation of section 3.307(a)(6)(iii) as requiring the servicemember's presence at some point on the landmass or the inland waters of Vietnam). Service connection may be established either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). The determination as to whether these requirements for service connection are met is based on an analysis of all the relevant evidence of record and the evaluation of its competency and credibility to determine its ultimate probative value in relation to other evidence. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). As an initial matter, the Board finds that the competent evidence of record confirms that the Veteran has been diagnosed with coronary artery disease and bilateral sensorineural hearing loss. Consequently, the determinative issue is whether or not these disabilities are attributable to his military service. Ischemic Heart Disease The appellant contends that that the Veteran's ischemic heart disease was due to exposure to Agent Orange during his service in Thailand and Vietnam. Here, the evidence shows that during the pendency of the appeal, the Veteran had a current diagnosis of ischemic heart disease, an enumerated disease associated with herbicide exposure under 38 C.F.R. § 3.309(e). See June 2010 VA outpatient treatment record diagnosing coronary artery disease. Service treatment records are negative for ischemic heart disease. On retirement medical examination in January 1973, the Veteran's heart was listed as normal. A chest X-ray study was negative, and an electrocardiogram was within normal limits. On VA examination in September 1973, the Veteran's heart was not enlarged, with a regular sinus rhythm, sounds of good quality, and no murmur, rubs or thrills. A chest X-ray study was normal and showed no cardiac abnormalities. In December 2009, the Veteran claimed service connection for heart disease from Agent Orange exposure. He said that while stationed in Thailand, he made trips to Vietnam to pick up equipment. During his lifetime, the Veteran contended that he was directly exposed to Agent Orange during service in Thailand, while he was stationed at Nakhon Phanom RTAFB, or, alternatively, that he set foot in Vietnam when he made a trip from Thailand to Saigon to pick up an engine stand used to test T64 engines, and is entitled to the presumption of herbicide exposure in Vietnam. See Veteran's statements dated in December 2009, September 2010, October 2010, December 2010, September 2011, October 2011, and March 2012. In an October 2010 telephone call, the Veteran said he had no military documents that would show he was on ground in the Republic of Vietnam (RVN). He said he was stationed in Thailand and worked on helicopters. He stated that sometime between August and November 1968, he was verbally instructed to pick up a test stand that was to arrive in RVN and bring it back to the base in Thailand. He states he signed the plane's manifest and he flew with the plane's crew to RVN. They picked up the test stand and returned to Thailand. The Veteran said that this was his only trip to RVN. In a December 2010 affidavit, the Veteran stated that he traveled to Saigon, Vietnam from Nakhon Phanom RTAFB in September or October 1968. In June 2010, the National Personnel Records Center indicated that it was unable to determine whether or not the Veteran served in the Republic of Vietnam. Multiple attempts to verify his presence in Vietnam have been unsuccessful. Therefore he is not presumed to have been exposed to herbicides based on service in the Republic of Vietnam during the Vietnam era. Recent findings indicate that herbicides were also used in Thailand. In May 2010, VA published a "Compensation & Pension (C&P) Service Bulletin" which establishes "New Procedures for Claims Based on Herbicide Exposure in Thailand and Korea." Compensation and Pension Bulletin, New Procedures for Claims Based on Herbicide Exposure in Thailand and Korea (May 2010); 2015 WL 65578 (Jan. 6, 2015). In explaining the need for the new procedures, the bulletin noted that there was significant use of herbicides on the fenced-in perimeters of military bases in Thailand intended to eliminate vegetation and ground cover for base security purposes. VA determined that a special consideration of herbicide exposure on facts found or direct basis should be extended to those veterans whose duties placed them on or near the perimeters of Thailand military bases. It was noted that the majority of troops in Thailand during the Vietnam era were stationed at the Royal Thai Air Force Bases of U-Tapao, Ubon, Nakhon Phanom, Udorn, Takhli, Korat, and Don Muang. It was also noted that if a U.S. Air Force Veteran served on one of these air bases as a security policeman, security patrol dog handler, member of a security police squadron, or otherwise served near the air base perimeter, as shown by MOS (military occupational specialty), performance evaluations, or other credible evidence, then herbicide exposure should be acknowledged on a facts found or direct basis. This applies only during the period from February 28, 1961 to May 7, 1975. (See May 2010 C&P Service Bulletin; Project CHECO Southeast Asia Report: Base Defense in Thailand; see also VA Adjudication Manual, M-21-1, Part IV, Subpart ii, Chapter 1, Section H, para. 5.a.,b.). In February 2011, the National Personnel Records Center stated that it found no records showing that the Veteran was exposed to herbicides. The Veteran's service personnel records reflect that he served in the U.S. Navy from September 1952 to August 1956, and in the U.S. Air Force from November 1956 to June 1973, including service in Thailand from August 1968 to August 1969. The Veteran's service personnel records show that he served in the U.S. Air Force in Thailand during the Vietnam era, at Nakhon Phanom Royal Thai Air Force Base (RTAFB), but do not demonstrate that he served in Vietnam. His service personnel records show that he was the non-commissioned officer in charge (NCOIC) of the jet engine shop of the 56th Field Maintenance Squadron (FMSq) at Nakhon Phanom RTAFB, Thailand, from August to November 1968, when he became the aircraft engine superintendent of that same unit, and then from February to August 1969 he was again the NCOIC of the jet engine shop there. He was responsible for build-up, tear down, and minor repair of all assigned jet engines. He did not serve as an Air Force security policeman, security patrol dog handler, or member of the security police squadron during the time he was assigned to Nakhon Phanom RTAFB. A November 1968 hearing conservation data form reflects that the Veteran was stationed at Nakhon Phanom RTAFB, and his primary work area was the hangar shop. In statements dated in September 2010, December 2010 September 2011 and March 2012, the Veteran said that his duties as a jet engine mechanic placed him at the perimeter of Nakhon Phanom RTAFB. He stated that Agent Orange was sprayed around the perimeter including the airfield where he worked. He said his job required him to work in close proximity to the fence line where Agent Orange was sprayed. He also reported working on A1Es that flew low-level missions to support the C-123 aircraft which actually sprayed Agent Orange, and that he worked on those aircraft which had possibly flown into the spray from the C-123s. In September 2011, he said that his primary job while stationed at Nakhon Phanom RTAFB was flight line maintenance on aircraft, and he worked in close proximity to the fence lines that secured the runway, and they could see the military police patrols and their dogs. He said he could not recall the exact distance to the perimeter fence, but it was very close. In an April 2015 statement, the appellant's representative stated that she had many conversations with the Veteran during his lifetime about his Agent Orange exposure. She said that the Veteran told her he worked on the flight line at Nakhon Phanom RTAFB, which was close to the perimeter fence, and that he recalled on several occasions walking through dripping vegetation after it had been sprayed with herbicides by the grounds keeping crews. The Board finds that the evidence of record clearly establishes that the Veteran had active service at one of the designated Thailand Air Force bases. He also served on active duty for a period of the Vietnam era during which VA has acknowledged that herbicides were used near those air base perimeters in Thailand. In statements made in support of the claim, it was indicated that the Veteran's MOS placed him at the perimeter of the military base. The above lay evidence is competent and credible, and there is no directly contradictory evidence. Viewing the evidence of record in a light most favorable to the appellant, the Board finds that this evidence is at least in relative equipoise regarding the Veteran's direct exposure to herbicide agents. The appellant has presented competent and credible lay evidence showing that the Veteran's work duties at Nakhon Phanom RTAFB frequently placed him at the perimeter of that base. As such, the Board concedes the Veteran's direct exposure to herbicides during his active service in Thailand. The Veteran's medical records demonstrate that he was diagnosed with coronary artery disease, i.e., ischemic heart disease. As the Board has conceded exposure to herbicides in Thailand, the Veteran's ischemic heart disease is presumed to be associated with his in-service herbicide exposure. See 38 C.F.R. § 3.309(e). There is no clear and convincing evidence to rebut this presumption. As a result, the Board finds that the evidence supports a grant of service connection for ischemic heart disease on a presumptive basis as a result of herbicide exposure. Bilateral Hearing Loss According to VA standards, impaired hearing only will be considered to be a ratable disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. In December 2009, the Veteran claimed service connection for hearing loss due to working on the flight line with jet engines for 20 years. The results of the Veteran's May 2013 VA examination show that his bilateral sensorineural hearing loss meets the threshold to be considered a disability for VA purposes. 38 C.F.R. § 3.385 (2015). Consequently, the determinative issue is whether or not this disability is attributable to his military service. The Veteran's DD Forms 214 reflect that he served in the U.S. Navy from September 1952 to August 1956, and in the U.S. Air Force from November 1956 to June 1973, including service in Thailand from August 1968 to August 1969, and his primary MOS was that of a jet engine mechanic. Service treatment records reflect that the Veteran had occupational noise exposure. On medical examination in March 1961, Rudmose audiometric testing revealed right ear decibel thresholds of -5, -5, 10, and -5, and left ear decibel thresholds of 0, -5, -10, and -5, at the respective frequencies of 500, 1000, 2000, and 3000 hertz. On medical examination in August 1968, ISO audiometric testing revealed right ear decibel thresholds of 0, 0, -5, 5, and 20, and left ear decibel thresholds of -5, -5, -5, 10, and 20, at the respective frequencies of 500, 1000, 2000, 3000, and 4000 hertz. On medical examination in April 1970, audiometric testing revealed right ear decibel thresholds of 5, 5, 5, 5, and 20, and left ear decibel thresholds of 5, 5, 5, 15, and 25, at the respective frequencies of 500, 1000, 2000, 3000, and 4000 hertz. A May 1972 form entitled hearing conservation data reflects that the Veteran had been in his current job for nineteen years, had noise exposure from aircraft, and primarily worked on the flight line, while wearing hearing protection. Audiometric testing revealed right ear decibel thresholds of 10, 5, 10, 10, and 25, and left ear decibel thresholds of 15, 10, 10, 20 and 25, at the respective frequencies of 500, 1000, 2000, 3000, and 4000 hertz. The examiner estimated his hearing as "fair." Audiometric testing (ANSI) on retirement examination in January 1973 revealed right ear decibel thresholds of 5, 5, 5, 10 and 30, and left ear decibel thresholds of 5, 5, 5, 15 and 15, at the respective frequencies of 500, 1000, 2000, 3000, and 4000 hertz. In a September 2011 statement, the Veteran noted that VA denied his claim of service connection for hearing loss based on an examiner's statement that he had more noise exposure after his retirement than during his 20+ years on the flight line in the military. He asserted that this was incorrect, and that while he did continue to work in the aviation field after retirement from the military, he did not work on the flight line, but instead worked in a supervisory capacity in an office. After a review of all of the evidence of record, including the Veteran's statements, the Board finds that his military service reflects noise exposure for many years. Moreover, the service treatment records reflect that his hearing acuity decreased during his many years of service even though the requirements of 38 C.F.R. § 3.385 were not met at his retirement examination. "[W]hen audiometric test results at a veteran's separation from service do not meet the regulatory requirements for establishing a 'disability' at that time, he or she may nevertheless establish service connection for a current hearing disability by submitting evidence that the current disability is causally related to service." Hensley v. Brown, 5 Vet. App. 155, 160 (1993); see also Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). The Veteran was afforded a VA audiological compensation examination by QTC in February 2010, at which time he reported working on the flight line during service with exposure to jet engine noise. He said he worked on reciprocating and jet engines. He said that after service he worked as an aircraft mechanic for 17 years. The audiologist confirmed current bilateral sensorineural hearing loss for VA purposes, and opined that it was at least as likely as not that the Veteran's current right ear hearing loss was a result of his military noise exposure in aircraft engine support because hearing loss occurs as a direct result of exposure to high intensity sound from jet engines. An opinion as to etiology was not provided with regard to the left ear hearing loss. In a May 2013 VA compensation examination, the VA examiner confirmed current bilateral hearing loss, and opined that it was at least as likely as not that the Veteran's current hearing loss was caused by or a result of an event in military service. The examiner noted that the Veteran denied serving in combat. The examiner determined that the Veteran's position as an airplane mechanic exposed him to excessive noise exposure. The examiner reviewed and commented on the Veteran's prior VA examination and on the Veteran's report that his post-military career did not involve testing engines after repairs were completed, and he was a supervisor in an office. The Board notes that the Veteran's service treatment records contain audiograms that report normal hearing for VA purposes. However, the May 2013 VA examiner opined that hearing loss was shown in service. Given the Veteran's diagnosed bilateral loss, conceded in-service noise exposure in his position as a jet engine mechanic, and the positive opinion by the May 2013 VA examiner that the Veteran's current hearing loss was at least as likely as not related to that noise exposure, the Board finds that the preponderance of the evidence shows that his bilateral hearing loss is related to service. Accordingly, service connection for bilateral hearing loss is granted. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2014); 38 C.F.R. § 3.102, 3.303, 3.385 (2015). ORDER Service connection for ischemic heart disease is granted. Service connection for bilateral hearing loss is granted. REMAND Although further delay is regrettable, the Board finds that further development is required prior to adjudication of the claims for service connection for strokes and skin cancer. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159 (2015). The appellant contends that the Veteran had two strokes in February 2012 secondary to his ischemic heart disease, and that he incurred skin cancer from prolonged sun exposure on the flight line during service. In this decision, the Board granted service connection for the Veteran's ischemic heart disease. As such, on remand, a VA medical opinion should be obtained to determine if his strokes were caused or aggravated by his service-connected ischemic heart disease. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). With regard to the claim of service connection for skin cancer, in a September 2011 statement, the Veteran contended that his sun exposure during active duty was much greater than the exposure after his retirement from active duty, since he worked in an office as a supervisor after service. The Veteran submitted a private medical opinion by D.K.D., MD, who opined that the Veteran had numerous actinic keratoses as well as numerous nonmelanoma skin cancers. He indicated that a significant risk factor for the development of actinic keratoses and nonmelanoma skin cancers is sun exposure. He stated, "His work history of being on the flight line for twenty years in intense sun certainly could contribute to the development of these lesions." The Board finds that Dr. D.'s medical opinion is equivocal, and that additional medical comment is needed. As there is a suggestion that the Veteran's skin cancer may be related to service, and insufficient competent medical evidence on file for VA to make a decision on the claim, the Board finds that this case must be remanded to obtain a VA medical opinion as to the etiology of the Veteran's diagnosed skin cancer. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4); Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). Relevant VA medical records should also be obtained. 38 U.S.C.A. § 5103A(c) (West 2014); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, the case is REMANDED for the following action: (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. With any necessary releases, obtain any relevant VA or private medical records of treatment for strokes or skin cancer that are not already on file, and associate them with the electronic claims file. 2. Obtain a VA medical opinion to determine the etiology of the Veteran's strokes. The claims file, to include this remand, must reviewed by the examiner and such review must be noted in the examination report. Following examination of the Veteran, the examiner is to provide an opinion to the following: a. Is it at least as likely as not (a 50 percent probability or more) that the Veteran's strokes are related to military service? b. Is it at least as likely as not (a 50 percent probability or more) that the Veteran's strokes were caused by the Veteran's service-connected ischemic heart disease? c. Is it at least as likely as not (a 50 percent probability or more) that the Veteran's strokes were aggravated by (i.e., permanently worsened beyond normal progression) the Veteran's service-connected ischemic heart disease? If aggravation is found, please give a baseline level of disability and a level of disability after aggravation. The examiner must provide a rationale for all opinions provided. If an opinion cannot be made without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 3. Obtain a VA medical opinion to determine the etiology of the Veteran's skin cancer. The electronic claims file must be made available to and reviewed by the examiner, including the September 2011 private medical opinion by D.K.D., MD. The examiner should specifically respond to the following question: Is it at least as likely as not (a 50 percent probability or more) that the Veteran's skin cancer was related to military service, to include sun exposure? The examiner must provide a rationale for all opinions provided. If an opinion cannot be made without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 4. If the benefits sought on appeal remain denied, the appellant and her representative should be provided a supplemental statement of the case (SSOC). Then the case should be returned to the Board, if in order. The appellant 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). ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs