Citation Nr: 1611654 Decision Date: 03/23/16 Archive Date: 03/29/16 DOCKET NO. 10-07 276 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for residuals of seminoma, with a right orchiectomy, to include as due to Agent Orange exposure. 2. Entitlement to service connection for an anxiety disorder, to include as secondary to service-connected posttraumatic stress disorder (PTSD) and depression. 3. Entitlement to service connection for bilateral knee disabilities, to include as due to Agent Orange exposure. 4. Entitlement to service connection for bilateral shoulder disabilities, to include as due to Agent Orange exposure. 5. Entitlement to service connection for a low back disability, to include as due to Agent Orange exposure. 6. Entitlement to service connection for a balance disorder, to include as due to Agent Orange exposure, as well as secondary to service-connected tinnitus. 7. Entitlement to service connection for balance issues, to include Meniere's disease, vertigo, and a cerebellar gait, claimed as due to Agent Orange exposure, as well as secondary to service-connected bilateral hearing loss. 8. Entitlement to service connection for residuals of a cerebrovascular accident, to include dysarthria and ataxia, to include as due to Agent Orange exposure, as well as secondary to service-connected PTSD and depression. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD S. D. Regan, Counsel INTRODUCTION The Veteran served on active duty from December 1967 to July 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal of rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. A November 2006 RO decision granted service connection and a 10 percent rating for tinnitus, effective August 4, 2005. Therefore, the issue of entitlement to service connection for tinnitus is no longer on appeal. The April 2007 RO decision denied service connection for depression and for an anxiety disorder. The September 2008 RO decision denied service connection for bilateral knee disabilities, bilateral shoulder disabilities, and for a low back disability. By this decision, the RO also denied service connection for a balance disorder, to include as secondary to service-connected tinnitus. The April 2010 RO decision denied service connection for Meniere's disease, vertigo, and a cerebellar gait, to include as secondary to service-connected bilateral hearing loss. By this decision, the RO also denied service connection for residuals of a cerebrovascular accident (listed as a stroke), to include dysarthria and ataxia. The October 2012 RO decision determined that new and material evidence had not been received to reopen a claim for entitlement to service connection for residuals of seminoma, with a right orchiectomy, to include as due to Agent orange exposure. When relevant service department records are received at any time after VA issues a decision on a claim and those records existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim. 38 C.F.R. § 3.156(c). In this case, however, the Board finds the service personnel records that were received after a May 1994 decision that denied service connection for residuals of seminoma, with a right orchiectomy, to include as due to Agent Orange exposure, are not relevant to the claim as they provide no evidence impacting the claim. The Veteran's exposure to Agent Orange was already conceded at the time of the May 1994 RO decision and there is no additional evidence in the service personnel records that is relevant to the Veteran's claim as to whether new and material evidence has been received to reopen the claim for entitlement to service connection for residuals of seminoma, with a right orchiectomy, to include as due to Agent Orange exposure. Moreover, the Court of Appeals for Veterans Claims has held that 38 C.F.R. § 3.156(c) only applies when VA receives official service department records that were unavailable at the time that VA previously decided a claim for benefits and those records lead VA to award a benefit that was not granted in the previous decision. Blubaugh v. McDonald, 773 F.3d 1310 (Fed. Cir. 2014). In this case, as shown by the discussion below, although the Board is reopening the Veteran's claim for entitlement to service connection for seminoma, with a right orchiectomy, to include as due to Agent Orange exposure, the Veteran's service personnel records have not led to the reopening of the Veteran's claim. Rather, that grant is based on a statement from the Veteran with an attached medical treatise. Additionally, the Board observes that the October 2012 RO decision (noted above) also addressed the issue of entitlement to service connection for depression and for an anxiety disorder on the basis of whether new and material evidence had been received. The RO essentially determined that new and material evidence had not been received to reopen that claim. The Board notes, however, that the prior April 2007 RO decision (noted above) that denied service connection for depression and for an anxiety disorder was not final. Additionally, the October 2012 RO decision (noted above) also addressed issues of entitlement to service connection for Meniere's disease, vertigo, and a cerebellar gait, to include as secondary to service-connected bilateral hearing loss, and entitlement to service connection for residuals of a cerebrovascular accident, to include dysarthria and ataxia, on the basis of whether new and material evidence had been received. The RO essentially determined that new and material evidence had not been received to reopen those claims. The Board observes, however, that the prior April 2010 RO decision that denied service connection for Meniere's disease, vertigo, and a cerebellar gait, to include as secondary to service-connected bilateral hearing, and that denied service connection for residuals of a cerebrovascular accident, to include dysarthria and ataxia, was not final. Therefore, the respective issues above will be addressed on a de novo basis. A March 2013 RO decision granted service connection for PTSD and assigned a 30 percent rating for the period from August 4, 2005 to July 5, 2011, and a 70 percent rating for the period since July 6, 2011. Therefore, the issue of entitlement to service connection for PTSD is no longer on appeal. A December 2013 RO decision granted service connection for depression (listed as PTSD with depression). The RO continued a 30 percent rating PTSD and depression for the period from August 4, 2005 to July 5, 2011, and a 70 percent rating for the period since July 6, 2011. Therefore, the issue of entitlement to service connection for depression is no longer on appeal. The Board observes that on multiple occasions prior to January 2015, the Veteran requested a Travel Board hearing at the RO. However, in January 2015, the Veteran withdrew his hearing requests. The issues have been recharacterized to comport with the evidence of record. The Veteran's reopened claim of entitlement to service connection for residuals of seminoma, with a right orchiectomy, as well as the issues of entitlement to service connection for an anxiety disorder; entitlement to service connection for bilateral knee disabilities, bilateral shoulder disabilities, and a low back disability; entitlement to service connection for a balance disorder; entitlement to service connection for Meniere's disease, vertigo, and a cerebellar gait; and entitlement to service connection for residuals of a cerebrovascular accident, to include dysarthria and ataxia, are all addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The RO denied service connection for residuals of seminoma, with a right orchiectomy, to include as due to Agent Orange exposure, in May 1994, and the Veteran did not appeal nor was new and material evidence received within the appeal period. 2. Evidence received since that decision includes evidence that is not cumulative or redundant, relates to an unestablished fact necessary to substantiate the claims, and raises a reasonable possibility of substantiating the claims. CONCLUSIONS OF LAW 1. The May 1994 RO decision that denied entitlement to service connection for residuals of seminoma, with a right orchiectomy, to include as due to Agent Orange exposure, is final. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. §§ 20.302, 20.1103 (2015). 2. New and material evidence has been received to reopen a claim for entitlement to service connection for residuals of seminoma, with a right orchiectomy, to include as due to Agent Orange exposure. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS A decision of the RO becomes final and is not subject to revision on the same factual basis unless a notice of disagreement is filed within one year of the notice of decision. 38 U.S.C.A. § 7105(c); 38 C.F.R. § 20.1103. If a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 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 the 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). In determining if new and material evidence has been submitted, the evidence is generally presumed to be credible. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). In addition, all of the evidence received since the last final disallowance shall be considered in making the determination. See Evans v. Brown, 9 Vet. App. 273, 283 (1996). In Shade v. Shinseki, 24 Vet. App. 110, 118 (2010), the United States Court of Appeals for Veterans Claims (Court) stated that when determining whether the submitted evidence meets the definition of new and material evidence, VA must consider whether the new evidence could, if the claim were reopened, reasonably result in substantiation of the claim. Id. at 118. Thus, pursuant to Shade, evidence is new if it has not been previously submitted to agency decisionmakers and is material if, when considered with the evidence of record, it would at least trigger VA's duty to assist by providing a medical opinion, which might raise a reasonable possibility of substantiating the claim. Id. New and material evidence received prior to the expiration of the appeal period, or prior to the appellate decision if a timely appeal has been filed (including evidence received prior to an appellate decision and referred to the agency of original jurisdiction by the Board of Veterans Appeals without consideration in that decision in accordance with the provisions of § 20.1304(b)(1)), will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has found that 38 C.F.R. § 3.156(b) requires that VA evaluate submissions received during the relevant period to determine whether they contain new and material evidence relevant to a pending claim, even if the new submission may support a new claim. Bond v. Shinseki, 659 F.3d 1362, 1367-68 (Fed. Cir. 2011). The RO denied service connection for residuals of seminoma, with a right orchiectomy, to include as due to Agent Orange exposure, in May 1994. The Board notes that there was no new and material evidence received within one year of the May 1994 RO decision. See 38 C.F.R. § 3.156(b); Bond, 659 F.3d at 1367-68. The May 1994 RO decision was not appealed and is considered final. 38 U.S.C.A. § 7105. The evidence considered at the time of the May 1994 RO decision included the Veteran's service treatment records; post-service private and VA treatment records; and the Veteran's own statements. The RO denied service connection for residuals of seminoma, with a right orchiectomy, to include as due to Agent Orange exposure (listed as seminoma secondary to herbicide/Agent Orange exposure) on the basis that the available scientific and medical evidence did not support the conclusion that such disorder was associated with Agent Orange exposure, and that there was no other basis for service connection. The RO also indicated that there was no evidence of seminoma, with a right orchiectomy, in service, or within one year of the Veteran's discharge from service. The RO further noted that VA had determined that a presumption of service connection based on herbicides (Agent Orange) used in Vietnam was not warranted for seminoma. The evidence received since the May 1994 RO decision includes service personnel records; additional post-service private and VA treatment records; VA examination reports; records from the Social Security Administration (SSA); copies of medical treatises; and statements from the Veteran. In a July 2011 statement, the Veteran reported that he had submitted a medical treatise from the National Cancer Institute at that National Institutes of Health, which listed the risk factors for seminoma. The Veteran stated that as he did not have any of the listed risk factors for seminoma, such disorder was either caused by Agent Orange exposure, or his Agent Orange exposure during service was a factor in the development of his seminoma. A Fact Sheet from the National Cancer Institute at the National Institutes of Health, apparently dated in May 2005, indicated that testicular cancer accounted for only one percent of all cancers in men in the United States. It was noted that testicular cancer occurred most often in men between the ages of twenty and thirty-nine and that it was the most common form of cancer in men between the ages of fifteen and thirty-four. The Fact Sheet from the National Cancer Institute at the National Institutes of Health further indicated that the exact causes of testicular cancer were not known, but that studies had shown that several factors increased a man's chances of developing the disease. Those factors were listed as an undescended testicle (cryptorchism); congenital abnormalities; a history of testicular cancer; and a family history of testicular cancer. The Veteran had written on a copy of the Fact Sheet that he had none of those risk factors. The Board observes that in the evidence available at the time of the May 1994 RO decision, there was no specific evidence relating the Veteran's current residuals of seminoma, with a right orchiectomy, to his period of service, including Agent Orange exposure. In his July 2011 statement, the Veteran specifically stated that he did not have any of the risk factors for seminoma, and that, therefore, he felt his Agent Orange exposure caused, or was at least a factor in the development of, his seminoma. The Veteran also specifically provided a Fact Sheet from the National Cancer Institute at the National Institutes of Health, apparently dated in May 2005, which listed risk factors for testicular cancer of undescended testicle (cryptorchism); congenital abnormalities; a history of testicular cancer; and a family history of testicular cancer. The Veteran's July 2011 statement, with the Fact Sheet from the National Cancer Institute at the National Institutes of Health, apparently dated in May 2005, possibly support the Veteran's contention of a relationship between his residuals of seminoma, with a right orchiectomy, to include as due to Agent Orange exposure, and his period of service. Additionally, the evidence will be considered credible for the purposes of determining whether new and material evidence has been submitted. The Board finds that the July 2011 statement from the Veteran, with the Fact Sheet from the National Cancer Institute at the National Institutes of Health, apparently dated in May 2005, are evidence that is both new and material because the claim was previously denied, at least in part, on the basis that the evidence did not show currently diagnosed residuals of seminoma, with a right orchiectomy, stemming from the Veteran's period of service, to include Agent Orange exposure. Therefore, the Board finds that such evidence is not cumulative or redundant, relates to an unestablished fact necessary to substantiate his claim, and raises a reasonable possibility of substantiating the claim. The Board concludes that evidence received since the May 1994 RO decision is new and material, and thus the claim for service connection for residuals of seminoma, with a right orchiectomy, to include as due to Agent Orange exposure, is reopened. See 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). The reopened claim for residuals of seminoma, with a right orchiectomy, to include as due to Agent Orange exposure, will be addressed further in the remand section. ORDER New and material evidence to reopen the claim for entitlement to service connection for residuals of seminoma, with a right orchiectomy, to include as due to Agent Orange exposure, has been received; to this limited extent, the appeal is granted. REMAND The remaining issues on appeal are entitlement to service connection for residuals of seminoma, with a right orchiectomy, to include as due to Agent Orange exposure; entitlement to service connection for an anxiety disorder, to include as secondary to service-connected PTSD and depression; entitlement to service connection for bilateral knee disabilities, bilateral shoulder disabilities, and a low back disability, all to include as due to Agent Orange exposure; entitlement to service connection for a balance disorder, to include as due to Agent Orange exposure, as well as secondary to service-connected tinnitus; entitlement to service connection for Meniere's disease, vertigo, and a cerebellar gait, to include as due to Agent Orange exposure, as well as secondary to service-connected bilateral hearing loss; and entitlement to service connection for residuals of a cerebrovascular accident, to include dysarthria and ataxia, to include as due to Agent Orange exposure, as well as secondary to service-connected PTSD and depression. The Veteran is service-connected for PTSD and depression. He is also service-connected for bilateral hearing loss and for tinnitus. The Veteran essentially contends that his residuals of seminoma, with a right orchiectomy; bilateral knee disabilities, bilateral shoulder disabilities; a low back disability; a balance disorder; Meniere's disease, vertigo, and a cerebellar gait, and residuals of a cerebrovascular accident, to include dysarthria and ataxia, are all related to his period of service. He also essentially indicates that his anxiety disorder is related to his period of service, or, more specifically, to his service-connected PTSD and depression. He further indicates, alternatively, that his balance disorder is related to his service-connected tinnitus; his Meniere's disease, vertigo, and cerebellar gait, are related to his service-connected bilateral hearing loss; and his residuals of a cerebrovascular accident, to include dysarthria and ataxia, are related to his service-connected PTSD and depression. The Veteran is competent to report having testicular problems; psychiatric problems; bilateral knee problems; bilateral shoulder problems; low back problems; balance problems; dizziness; and gait problems during service and since service. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Veteran's service treatment records show treatment for a possible low back problem on one occasion. Such records show no complaints, findings, or diagnoses of seminoma or testicular problems; psychiatric problems; bilateral knee problems; bilateral shoulder problems; balance problems; Meniere's disease, vertigo, or gait problems; or a cerebrovascular accident, to include dysarthria and ataxia. A January 1968 radiological report, as to the Veteran's lumbar spine, noted that the Veteran suffered an injury to his lumbar spine about ten months earlier. The examiner noted that the radiological report was negative. Post-service private and VA treatment records show treatment for seminoma, with a right orchiectomy, as well as treatment for an anxiety disorder; bilateral knee complaints; bilateral shoulder complaints; low back complaints; a balance disorder; Meniere's disease; vertigo; a cerebellar gait; and for a cerebrovascular accident with dysarthria and ataxia. The Board observes that the Veteran has not been afforded VA examinations, with the opportunity to obtain responsive etiological opinions, following a thorough review of the entire claims folder as to his claims for service connection for residuals of seminoma, with a right orchiectomy; bilateral knee disabilities; bilateral shoulder disabilities; and for a low back disability, all to include as due to Agent Orange exposure. The Board finds that such examinations must be accomplished on remand. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). As to the Veteran's claim for entitlement to service connection for anxiety, to include as secondary to service-connected PTSD and depression, the Board notes that a July 2011 VA psychiatric examination report included a notation that the Veteran's claims file was reviewed. The diagnosis was PTSD, chronic. The examiner indicated that PTSD was the only diagnosis given and that any depressed or anxious mood that the Veteran experienced was secondary to his PTSD symptoms. The Board observes that the examiner solely diagnosed the Veteran with PTSD. However, treatment reports of record include diagnoses of anxiety. The Board notes that the "current disability" requirement for service connection is satisfied if a claimant has a disability at any time during the pendency of a claim, even if the disability resolves prior the adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Board also notes that the examiner did not address whether any diagnosed anxiety disorder was related to the Veteran's period of service, or whether any such disorder was caused or aggravated by his service-connected PTSD and depression. The Board observes that there are several VA examination reports, and/or VA medical opinions of record, that address, at least in part, the Veteran's claims for entitlement to service connection for a balance disorder, to include as due to Agent Orange exposure, as well as secondary to service-connected tinnitus; entitlement to service connection for Meniere's disease, vertigo, and a cerebellar gait, to include as due to Agent Orange exposure, as well as secondary to service-connected bilateral hearing loss; and entitlement to service connection for residuals of a cerebrovascular accident, to include dysarthria and ataxia, to include as due to Agent Orange exposure, as well as secondary to service-connected PTSD and depression. For example, an August 2006 VA ear disease examination report included a notation that the Veteran's claims file was reviewed. The diagnoses were bilateral hearing loss and bilateral tinnitus. The examiner reported that the Veteran did not have Meniere's disease. An August 2008 statement from a VA physician indicated that only the Veteran's VA treatment records were reviewed. The examiner indicated that the Veteran's vertigo was not caused by or a result of his service-connected tinnitus. The examiner stated that the Veteran had a brain stem cerebrovascular accident in 1993, and that since that time, he had complained of vertigo, an inability to walk without a walker, and ataxia with severe speech difficulty. The examiner maintained that the Veteran's problem was ataxia, not vertigo, and that such was caused by his cerebrovascular accident. The examiner indicated that vertigo was not caused by his service-connected tinnitus. The Board observes that the examiner, pursuant to the August 2006 VA ear disease examination report, indicated that the Veteran did not have Meniere's disease. However, the Veteran's VA treatment records include diagnoses of Meniere's disease. For example, a December 1993 VA treatment entry related an assessment of Meniere's syndrome with tinnitus. A February 1994 treatment entry indicated that the Veteran was seen with Meniere's syndrome and tinnitus. Additionally, the VA physician, in his August 2008 statement, found that the Veteran did not have vertigo and that such disorder was not caused by his service-connected tinnitus. The physician indicated that the Veteran's ataxia was a result of his service-connected cerebrovascular accident. The Board notes, however, that although the physician indicated that the Veteran did not have vertigo, a February 1993 VA treatment entry related an impression of vertigo, an inner ear infection and an upper respiratory infection. Additionally, the Board observes that the examiner did not address whether the Veteran's claimed cerebrovascular accident, to include dysarthria and ataxia, was related to his period of service, to include Agent Orange exposure, or to his service-connected PTSD and depression. A September 2013 VA neurological examination report noted that the Veteran's claims file was not reviewed. The diagnosis was a history of a cerebrovascular accident in 1993. The examiner indicated that the claimed disorder was at least as likely as not (50 percent or greater probability) proximately due to or the result of the Veteran's service-connected PTSD. The examiner stated that the Veteran's PTSD symptoms included anger bursts and violence that could have trigger the onset of a stroke. The Board observes that the examiner did not review the Veteran's claims file. Additionally, the examiner's opinion is speculative in that it solely indicates that the Veteran's PTSD "could" have triggered the onset of a cerebrovascular accident. See Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). A March 2015 statement from a VA examiner (an advanced practice registered nurse) included a notation that the Veteran's claims file was reviewed. The examiner reported that there was no diagnosis of Meniere's syndrome in the records and that the Veteran's ataxia was secondary to his cerebrovascular accident. It was noted that ataxia was a neurological sign consisting of a lack of voluntary coordination of muscle movements. The examiner also stated that ataxia was a non-specific clinical manifestation implying dysfunction of the parts of the nervous system that coordinated movement, such as the cerebellum. The examiner indicated that the Veteran's ataxia was secondary to a stroke that he suffered in 1993, and that his gait disturbance was secondary to ataxia. The examiner maintained that a thorough review of the record did show a diagnosis of Meniere's syndrome. It was noted that the Veteran had a notation of nystagmus on examinations and that such was secondary to his cerebellar cerebrovascular accident. The examiner related that the Veteran had a brain stem cerebrovascular accident in 1993 and that, since that time, he had complained of vertigo, an inability to walk without a walker, and ataxia with severe speech difficulty. The examiner stated that the Veteran's problem was ataxia, not vertigo, which was caused by his cerebrovascular accident. It was noted that vertigo is not caused by tinnitus. The Board observes that the examiner indicated that there were no diagnoses of Meniere's disease of record. However, as noted above, VA treatment reports of record include diagnoses of Meniere's disease. Additionally, the physician did not address whether the Veteran's residuals of a cerebrovascular accident with dysarthria and ataxia were related to his period of service, to include Agent Orange exposure, or to his service-connected PTSD with depression. In an April 2015 addendum to the September 2013 VA neurological examination report, a different examiner, after a review of the claims file, indicated that the Veteran's claimed residuals of a cerebrovascular accident, to include dysarthria and ataxia, were less likely than not (less than 50 percent probability) proximately due to or the result of his service-connected PTSD and depression. The examiner stated that he disagreed with the examiner, pursuant to the September 2013 VA neurological examination report. The examiner stated that there was no medical evidence to indicate that the Veteran's cerebrovascular accident was the result of, or caused by, his PTSD. The examiner stated that there was no pathophysiologic relationship. It was noted that a cerebrovascular accident was either the result of a clot formed on a ruptured plaque (with or without embolization) or a hemorrhage. The examiner stated that such was caused by cholesterol an aneurysm, respectively. The examiner reported that major risk factors included hyperlipidemia and hypertension, and not PTSD. The Board observes that the VA examiner did not address whether the Veteran's claimed residuals of a cerebrovascular accident, to include dysarthria and ataxia, were related to his period of service, to include Agent Orange exposure. In light of the deficiencies with the examination reports and medical opinions discussed above, the Board concludes that the Veteran has not been afforded sufficient VA examinations, with the opportunity to obtain responsive etiological opinions, following a thorough review of the entire claims folder, as to his claims for entitlement to service connection for a balance disorder, to include as due to Agent Orange exposure, as well as secondary to service-connected tinnitus; entitlement to service connection for Meniere's disease, vertigo, and a cerebellar gait, to include as due to Agent Orange exposure, as well as secondary to service-connected bilateral hearing loss; and entitlement to service connection for residuals of a cerebrovascular accident, to include dysarthria and ataxia, to include as due to Agent Orange exposure, as well as secondary to service-connected PTSD and depression. Such examinations must be accomplished on remand. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 311-312 (2006). Prior to the examinations, any outstanding records of pertinent treatment should be obtained and added to the record. Accordingly, this issue is REMANDED for the following actions: 1. Ask the Veteran to identify all medical providers who have treated him for his claimed disorders since September 2014. Obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise him that he may obtain and submit those records. 2. Thereafter, schedule the Veteran for a VA examination by an appropriate medical professional to determine the nature and likely etiology of his claimed residuals of seminoma, with a right orchiectomy, to include as due to Agent Orange exposure. The entire claims file, including all electronic files, must be reviewed by the examiner. Based on a review of the claims file, examination of the Veteran, and generally accepted medical principles, the examiner must provide a medical opinion, with adequate rationale, as to whether it is as at least as likely as not (a 50 percent or greater probability) that the Veteran's residuals of seminoma, with a right orchiectomy, are etiologically related to or had their onset during his period of service. The examiner must also indicate whether the Veteran's residuals of seminoma, with a right orchiectomy, are related, at least in part, to his presumed in-service Agent Orange exposure, even though seminoma is not listed as an Agent Orange presumptive disability. The examination report must include a complete rationale for all opinions expressed. 3. Schedule the Veteran for a VA examination by an appropriate medical professional to determine the nature and likely etiology of his claimed anxiety disorder, to include as secondary to service-connected PTSD and depression. The entire claims file, to include all electronic files, must be reviewed by the examiner. The examiner must specifically indicate whether the Veteran has a diagnosed anxiety disorder. Based on a review of the claims file, examination of the Veteran, and generally accepted medical principles, the examiner must provide a medical opinion, with adequate rationale, as to whether it is as at least as likely as not (a 50 percent or greater probability) that any currently diagnosed anxiety disorder is related to and/or had their onset during his period of service. The examiner must specifically acknowledge and discuss any reports of the Veteran of anxiety during service and since service. The examiner must further opine as to whether the Veteran's service-connected PTSD and depression caused or aggravated any currently diagnosed anxiety disorders. The term "aggravation" means a permanent increase in the claimed disability; that is, a worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. If aggravation of any diagnosed anxiety disorder by the Veteran's service-connected PTSD and depression is found, the examiner must attempt to establish a baseline level of severity of the diagnosed anxiety disorder prior to aggravation by the service-connected PTSD and depression. The examination report must include a complete rationale for all opinions expressed. 4. Schedule the Veteran for a VA examination by an appropriate medical professional to determine the nature and likely etiology of his claimed bilateral knee disabilities, bilateral shoulder disabilities, and low back disability, to include as due to Agent Orange exposure. The entire claims file, including all electronic files, must be reviewed by the examiner. The examiner must diagnose all current bilateral knee disabilities, bilateral shoulder disabilities, and low back disabilities. Based on a review of the claims file, examination of the Veteran, and generally accepted medical principles, the examiner must provide a medical opinion, with adequate rationale, as to whether it is as at least as likely as not (a 50 percent or greater probability) that any diagnosed bilateral knee disabilities, bilateral shoulder disabilities, and low back disabilities, are etiologically related to or had their onset during his period of service. The examiner must also indicate whether any diagnosed bilateral knee disabilities, bilateral shoulder disabilities, and low back disabilities, are related, at least in part, to his presumed in-service Agent Orange exposure, even if any such diagnosed bilateral knee, bilateral shoulder, and low back disabilities are not listed as an Agent Orange presumptive disability. The examiner must specifically acknowledge and discuss any reports of the Veteran of bilateral knee problems, bilateral shoulder problems, and low back problems during service and since service. The examination report must include a complete rationale for all opinions expressed. 5. Schedule the Veteran for a VA examination by an appropriate medical professional to determine the nature and likely etiology of his claimed balance disorder, to include as due to Agent Orange exposure, as well as secondary to service-connected tinnitus. The entire claims file, including all electronic files, must be reviewed by the examiner. The examiner must diagnose all current balance disorders. Based on a review of the claims file, examination of the Veteran, and generally accepted medical principles, the examiner must provide a medical opinion, with adequate rationale, as to whether it is as at least as likely as not (a 50 percent or greater probability) that any currently diagnosed balance disorders are etiologically related to or had their onset during his period of service. The examiner must also indicate whether any diagnosed balance disorders are related, at least in part, to the Veteran's presumed in-service Agent Orange exposure, even if any diagnosed balance disorders are not listed as an Agent Orange presumptive disability. The examiner must specifically acknowledge and discuss any reports of the Veteran of balance problems during service and since service. The examiner must further opine as to whether the Veteran's service-connected tinnitus, or any other service-connected disabilities, caused or aggravated any diagnosed balance disorders. The term "aggravation" means an increase in the claimed disability; that is, a worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. If aggravation of any diagnosed balance disorders by the Veteran's service-connected tinnitus, or any other service connected disabilities, is found, the examiner must attempt to establish a baseline level of severity of any such diagnosed balance disorders prior to aggravation by the service-connected disability. The examination report must include a complete rationale for all opinions expressed. 6. Schedule the Veteran for a VA examination by an appropriate medical professional to determine the nature and likely etiology of his claimed Meniere's disease, vertigo, and a cerebellar gait, to include as due to Agent Orange exposure, as well as secondary to service-connected bilateral hearing loss. The entire claims file, including all electronic files, must be reviewed by the examiner. The examiner must specifically indicate if the Veteran has diagnosed Meniere's disease, vertigo, and a cerebellar gait. If the examiner finds the Veteran currently does not, and did not at any time during the course of the appeal, have diagnosed Meniere's disease, vertigo, and a cerebellar gait, the examiner must indicate why the diagnoses of those disorders reflected in the record are not valid diagnoses. Based on a review of the claims file, examination of the Veteran, and generally accepted medical principles, the examiner must provide a medical opinion, with adequate rationale, as to whether it is as at least as likely as not (a 50 percent or greater probability) that any currently diagnosed Meniere's disease, vertigo, and a cerebellar gait, are etiologically related to or had their onset during his period of service. The examiner must also indicate whether any diagnosed Meniere's disease, vertigo, and a cerebella gait, are related, at least in part, to the Veteran's presumed in-service Agent Orange exposure, even if any diagnosed Meniere's disease, vertigo, and a cerebellar gait, are not listed as an Agent Orange presumptive disability. The examiner must specifically acknowledge and discuss any reports of the Veteran of dizziness and gait problems during service and since service. The examiner must further opine as to whether the Veteran's service-connected bilateral hearing loss, or any other service-connected disabilities, caused or aggravated any diagnosed Meniere's disease, vertigo, and a cerebellar gait. The term "aggravation" means an increase in the claimed disability; that is, a worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. If aggravation of any diagnosed Meniere's disease, vertigo, and a cerebellar gait by the Veteran's service-connected bilateral hearing loss, or any other service connected disabilities, is found, the examiner must attempt to establish a baseline level of severity of any such diagnosed disorders prior to aggravation by the service-connected disability. The examination report must include a complete rationale for all opinions expressed. 7. Schedule the Veteran for a VA examination by an appropriate medical professional to determine the nature and likely etiology of his claimed residuals of a cerebrovascular accident, to include dysarthria and ataxia, to include as due to Agent Orange exposure, as well as secondary to service-connected PTSD and depression. The entire claims file, including all electronic files, must be reviewed by the examiner. The examiner must diagnose all current residuals of a cerebrovascular accident and must indicate whether the Veteran has currently diagnosed dysarthria and ataxia. Based on a review of the claims file, examination of the Veteran, and generally accepted medical principles, the examiner must provide a medical opinion, with adequate rationale, as to whether it is as at least as likely as not (a 50 percent or greater probability) that any currently diagnosed residuals of a cerebrovascular accident, to include any diagnosed dysarthria and ataxia, are etiologically related to or had their onset during his period of service. The examiner must also indicate whether any diagnosed residuals of a cerebrovascular accident, to include any diagnosed dysarthria and ataxia, are related, at least in part, to the Veteran's presumed in-service Agent Orange exposure, even if any diagnosed residuals of a cerebrovascular accident, to include any diagnosed dysarthria and ataxia, are not listed as an Agent Orange presumptive disability. If the examiner finds that any diagnosed residuals of a cerebrovascular accident, to include any diagnosed dysarthria and ataxia, are due to hypertension, the opinion must include consideration that the National Academy of Sciences Institute of Medicine has concluded that there is "limited or suggestive evidence of an association" between herbicide exposure (e.g. Agent Orange) and hypertension. The examiner must further opine as to whether the Veteran's service-connected PTSD and depression, or any other service-connected disabilities, caused or aggravated any diagnosed residuals of a cerebrovascular accident, to include any diagnosed dysarthria and ataxia. The term "aggravation" means an increase in the claimed disability; that is, a worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. If aggravation of any diagnosed residuals of a cerebrovascular accident, to include any diagnosed dysarthria and ataxia, by the Veteran's service-connected bilateral PTSD and depression, or any other service connected disabilities, is found, the examiner must attempt to establish a baseline level of severity of any such diagnosed disorders prior to aggravation by the service-connected disability. The examination report must include a complete rationale for all opinions expressed. 8. Finally, readjudicate the issue remaining on appeal. If any of the benefits sought remain denied, issue a supplemental statement of the case, and return the case to the Board. The Veteran 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). ______________________________________________ M. HYLAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs