Citation Nr: 1633549 Decision Date: 08/25/16 Archive Date: 08/31/16 DOCKET NO. 11-00 296A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial compensable disability rating for bilateral hearing loss. 2. Entitlement to service connection for a sleep disorder claimed as sleep apnea. 3. Entitlement to service connection for leukemia or non-Hodgkin's lymphoma. 4. Entitlement to service connection for subclass 1 of IgA immunoglobulin. 5. Entitlement to service connection for sinusitis. 6. Entitlement to service connection for a breathing condition, to include asthma. 7. Entitlement to service connection for hypertension. 7. Entitlement to service connection for joint pain. 8. Entitlement to service connection for a mental disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Azizi-Barcelo, Counsel INTRODUCTION The Veteran served on active duty from January1974 to April 1977. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision of a Department of Veterans Affairs Regional Office (RO). In April 2016, the Veteran testified at a travel Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is in the record. Following the hearing, the appellant submitted additional evidence in support of his claims and waived the right to have the evidence initially considered by the RO. 38 C.F.R. § 20.1304(c) (2015). The claims for entitlement to service connection for an immunological disorder, sinusitis, breathing disorder, hypertension, joint pain, and a mental health disability, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Throughout the pendency of the appeal the Veteran's bilateral hearing loss has been manifested by impairment of auditory acuity that is noncompensably disabling. 2. The Veteran does not have sleep apnea that was incurred in or is otherwise related to service. 3. The preponderance of the evidence is against a finding that the Veteran has leukemia or non-Hodgkin's lymphoma that is the result of a disease or injury in active duty service. CONCLUSIONS OF LAW 1. The criteria for a compensable evaluation for bilateral hearing loss are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.85, Diagnostic Code 6100, 4.86 (2015). 2. The requirements to establish service connection for sleep apnea have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. § 3.303 (2015). 3. The requirements to establish service connection for leukemia or non-Hodgkin's lymphoma have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. § 3.303 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist VA has a duty to notify and assist a claimant in the development of a claim. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2015). VA must notify a claimant of what information or evidence is necessary to substantiate the claim; what information or evidence, if any, the claimant is to provide; and what information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2015). Here, notice was provided by correspondence in December 2008, January 2009 and January 2012. The claims were last readjudicated in March 2016. Concerning the claim for an increased rating for bilateral hearing loss, the claim arises from the initial award of service connection. In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the Court held that in cases in which service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 490-91; see also Dunlap v. Nicholson, 21 Vet. App. 112 (2007) (section 5103(a) notice is no longer required after service-connection is awarded); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Concerning the duty to assist, the record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran including service treatment records, post-service treatment records, Social Security Administration records and VA examination reports were obtained to evaluate the claim for an increased rating for bilateral hearing loss. With regards to the claim for service connection for sleep apnea, a VA examination is not required in the absence of competent and credible evidence showing an event, disease, or injury during the Veteran's service or relating current sleep apnea to the Veteran's service. Concerning the claim for service connection for leukemia or non-Hodgkin's lymphoma, in the absence of evidence of a currently diagnosed disability or residuals thereof, development for VA medical examination is not warranted. Thus, a VA medical examination is not required. McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 U.S.C.A. § 5103A(d)(2) (West 2002); 38 C.F.R. § 3.159(c)(4)(i) (2013). Based on a review of the record, the Board finds that there is no indication that any additional evidence relevant to the issues to be decided herein is available and not part of the claims file. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Therefore, the Board will proceed to review the merits of the issues on appeal. Higher Rating The Veteran contends that he is entitled to a compensable disability rating for hearing loss. He reports difficulty understanding conversations, particularly in crowds, and trouble hearing soft voices such as whispers. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Evaluations of bilateral defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 Hertz (Hz). To evaluate the degree of disability from bilateral service-connected defective hearing, the Rating Schedule establishes 11 auditory acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100. The evaluation of hearing impairment applies a rather structured formula that is essentially a mechanical application of the rating schedule to numeric designations after audiology evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). On VA audio examination in September 2009, the puretone thresholds in decibels at the tested frequencies of 1000, 2000, 3000, and 4000 Hz were 20, 15, 20, 25 and 50 in the right ear; and in the left ear were 15, 15, 25, 60, and 65. The puretone threshold average in the right ear was 28 decibels and the average in the left ear was 41 decibels. Speech discrimination was 96 percent, bilaterally. For the right ear, the average pure tone threshold of 28 decibels, along with a speech discrimination percentage of 96 warrants a designation of Roman Numeral I under Table I of 38 C.F.R. § 4.85. For the left ear, the average pure tone threshold of 41 decibels, along with a speech percentage of 96 percent warrants a designation of Roman Numeral I under Table I of 38 C.F.R. § 4.85. Under Table VII of 38 C.F.R. § 4.85, where the right ear is Roman Numeral I, and the left ear is Roman Numberal I, the appropriate rating is 0 percent under DC 6100. On VA audio examination in March 2016, the puretone thresholds in decibels at the tested frequencies of 1000, 2000, 3000, and 4000 Hz were 25, 25, 15, 25, and 55 in the right ear; and in the left ear were 20, 15, 35, 40, and 65. The puretone threshold average in the right ear was 29 decibels and the average in the left ear was 35 decibels. Speech discrimination was 98 percent in the right ear and 94 percent in the left ear. Based on the results of this examination, for the right ear, the average pure tone threshold of 29 decibels, along with a speech discrimination percentage of 98 warrants a designation of Roman Numeral I under Table I of 38 C.F.R. § 4.85. For the left ear, the average pure tone threshold of 35 decibels, along with a speech percentage of 94 percent warrants a designation of Roman Numeral I under Table I of 38 C.F.R. § 4.85. Under Table VII of 38 C.F.R. § 4.85, where the right ear is Roman Numeral I, and the left ear is Roman Numberal I, the appropriate rating is 0 percent under DC 6100. Although the severity of the Veteran's hearing loss appears to have fluctuated somewhat during the appeal period, at no time did he have hearing loss that met the criteria for the assignment of a compensable disability rating. In reaching this finding, the Board has considered the written statements the Veteran submitted in support of his claim, and his testimony before the Veterans law Judge in 2016. While the Board has considered this evidence in light of Martinak v. Nicholson, 21 Vet. App. 447, 455-56 (2007) and the provisions of 38 C.F.R. § 3.321(b)(1), the Board does not find that the Veteran has described functional effects that are "exceptional" or not otherwise contemplated by the assigned evaluations. Rather, his description of difficulties with hearing loss is consistent with the degree of disability addressed by the assigned evaluation. The Board is sympathetic to the Veteran's contentions regarding the severity of his service-connected hearing loss. However, according to the audiometric test results, as compared to the rating criteria, the Board concludes that a compensable rating for hearing loss is not warranted. As a final matter, the Veteran does not contend and the record does not suggest that he is unemployable due to his hearing loss. Accordingly, a claim for a total disability rating based on unemployability due to hearing loss has not been raised and no action pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009) is necessary. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2014); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Service connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition 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)). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Moreover, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and leukemia becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2015). The Board has reviewed all the evidence in the record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Sleep apnea The Veteran's service treatment records do not contain any complaints, symptoms or findings consistent with a sleep disorder, to include sleep apnea. After service, a polysomnogram in July 2008 revealed obstructive sleep apnea. Subsequent treatment records document treatment for obstructive sleep apnea. The treatment record is silent in regard to when symptoms of obstructive sleep apnea began or as to the etiology of the disorder. As such, the evidence shows the Veteran to be diagnosed with sleep apnea, but there is no evidence--to include lay evidence--that he had the disorder during service. There is no indication of sleep apnea symptoms until 2008, more than 30 years after service, at which time it was diagnosed. The Veteran has not explained why he believes his claimed disability is somehow related to service, and there is no medical opinion of record asserting a relationship between the claimed sleep apnea and service. In sum, there is no medical or even lay evidence whatsoever that supports a relationship between sleep apnea and service. Based on the evidence and analysis above the Board finds the Veteran does not have sleep apnea that is incurred in or otherwise related to service; accordingly, the claim must be denied. Because the preponderance of the evidence is against the Veteran's claim the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2014); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). 2. Leukemia or non-Hodgkin's lymphoma The Veteran is seeking entitlement to service connection for leukemia or non-Hodgkin's lymphoma. He asserts that elevated white blood cell count noted in service, as well as recurrent fevers, were manifestations of the disorder. He claims he developed the condition due to exposure to jet fuel and combustion fumes, as well as military occupational exposure to radiation from nuclear weapons. He has reported that he guarded missiles and nuclear weapons as a security policeman while stationed at Ellsworth Air Force Base. The Veteran's military personnel form DD 214 listed his primary military occupational specialty as administrative specialist with a secondary military occupational specialty as security policeman. The service treatment records show that in April 1977, the examiner noted the urinalysis had 40 to 50 white blood cells, and split urine both showed 20 to 25 white blood cells. The examiner determined that the most likely diagnosis was prostatitis and as such, he could not recommend the separation be completed on the basis of medical problems. However, it was noted that the Veteran wanted to be separated from military service and he signed a waiver for his release. A review of the service treatment records reveals no complaints, treatment, or diagnoses of leukemia or non-Hodgkin's lymphoma. The Veteran's post-service treatment records reflect a history of lymphoma and leukemia in remission. VA treatment records in 2011 noted that the Veteran's report of having leukemia in 1972. Currently, there is no medical evidence of record suggesting that the Veteran has diagnoses of or complications related to lymphoma or leukemia. The threshold requirement for service connection to be granted is competent medical evidence of the current existence of the claimed disorder. See Dermatech v. Brown, 104 F.3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992). While the Board recognizes the Veteran's sincere belief in his claim, the competent medical evidence of record does not show the Veteran to have a current diagnosis of lymphoma or leukemia or to have residuals or complications related to service. Thus, without a specific diagnosis of a current disability related to lymphoma or leukemia, there may be no service connection for this claimed disability on a direct or a presumptive basis. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (which stipulates that a service connection claim may be granted if a diagnosis of a chronic disability was made during the pendency of the appeal, even if the most recent medical evidence suggests that the disability resolved). The Board has considered the Veteran's contentions that his fevers and abnormal white blood cell count developed into lymphoma or leukemia. While the Board has considered the Veteran's lay assertions, the Board ultimately finds that the Veteran, as a layperson, is not capable of linking lymphoma or leukemia to symptoms or clinical findings noted in service. There is no indication in the claims file that he has medical training or expertise that would render him competent to make such a link. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, as the medical evidence of record does not reflect that the Veteran has a current diagnosis of lymphoma or leukemia, and the Veteran is not competent as a lay person to link either claimed disability to symptoms or clinical findings in service or to diagnose himself with residuals of lymphoma or leukemia, service connection cannot be granted. As the preponderance of the evidence is against the claim for service connection for non-Hodgkin's lymphoma or leukemia, the benefit-of-the-doubt rule does not apply, and this claim must be denied. See 38 U.S.C.A. § 5107(b) (West 2014); Ortiz, supra; Gilbert, supra. ORDER A compensable rating for hearing loss is denied. Service connection for a sleep disorder, claimed as sleep apnea, is denied. Service for leukemia or non-Hodgkin's lymphoma is denied. REMAND The Veteran asserts that his immunological disorder, sinusitis, hypertension, joint pain, and a breathing disorder, are due to exposure to radiation and other environmental hazards, including contaminated water, jet fuel and combustion fumes while stationed at Ellsworth Air Force Base. He also asserted that hypertension is due to exposure to Agent Orange while stationed at Ellsworth Air Force Base. Initially, pertaining to the Veteran's contention of exposure to ionizing radiation, although the RO requested that the Veteran provide information pertaining to radiation exposure during service in a January 2012 letter, the record does not reflect that the RO has developed the Veteran's claims as radiation-exposure claims. In order to verify and quantify any such exposure, the AOJ should request dose information utilizing appropriate development procedures as described in 38 C.F.R. § 3.311(a)(2), to potentially include requesting the Veteran's Record of Occupational Exposure to Ionizing Radiation (DD Form 1141). Next, in addition to asserting that his immunological disorder, subclass 1 of IgA immunoglobulin, is due to exposure to radiation, at the April 2016 Board hearing the Veteran argued that abnormal white blood cell count noted in service was an initial manifestation of his currently diagnosed immunological disability which remained symptomatic since that time. As noted, the service treatment records show that prior to discharge from service in April 1977, urinalysis revealed abnormalities in the Veteran's white blood cell count. In support of his claim, the Veteran has submitted several medical opinion statements. In a 2008 statement Dr. Varraux noted a diagnosis of a immunodeficiency and opined that it was as likely as not that the condition could be related to military service. Also in 2008 Dr. Gonzales noted that the Veteran's immunodeficiency disorder was directly related to his service in the military. In a May 2016 statement a private physician opined that clinical findings noted in service pertaining to blood cell elevation and infections were due to Agent Orange exposure and working close to nuclear weapons. In April 2016 a physician also noted that immunodeficiency was due to radiation exposure in the military. The private opinion reports are not accompanied by adequate rationale and, therefore, are insufficient reason or basis to grant his claim. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Veteran underwent a VA examination in March 2016. The examiner diagnosed IgA subclass 1 immune deficiency and stated that it would be resort to mere speculation to state whether the Veteran may have had a genetic abnormality that may have been caused by the exposure to nuclear weapons. The examiner explained that selective IgA deficiency was believed to be a heterogeneous disorder that arises through several pathogenic mechanisms and is associated with several types of genetic abnormalities which include molecular defects, large chromosomal abnormalities, major histocompatibility; abnormalities in genes associated with autoimmunity and familiar inheritance of selective IgA deficiency which occurs in approximately 10 to 20 percent of cases. She also noted that service members in military occupations that involved exposure to nuclear weapons received special training and were monitored to ensure radiation exposure remained at safe levels. However, the Veteran's contentions that abnormal white blood cell count noted in service was an initial manifestation of the Veteran's immunological disorder has yet to be addressed. Accordingly, a VA examination that addresses the Veteran's contentions should be obtained. Concerning the claims for joint pain, sinusitis and a respiratory disorder, the evidence shows that the Veteran has been diagnosed and treated for a sinus condition and respiratory disorders, to include chronic obstructive pulmonary disease (COPD) and asthma. The Veteran has also been diagnosed with polymyalgia rheumatica. A VA examiner in March 2016 opined, based on review of all medical records available, history and examination of the Veteran, that the Veteran's polymyalgia rheumatica was less likely as not directly related to the flu-like symptoms of "pain in both legs and feet" noted on active duty. The examiner, however, determined that the Veteran's polymyalgia rheumatica might be related to the IgA immunodeficiency. The examiner explained that individuals with selective IgA immunodeficiency usually presented with one or more of the following disorders: autoimmune disorders; allergic disorders; recurrent sinopulmonary infections; allergic diseases and asthma. This reasonably raises the possibility of service connection on a secondary basis. 38 C.F.R. § 3.310. Thus, the Veteran's secondary service connection claims for a respiratory disorder, a sinus disorder and joint pain are inextricably intertwined with the claim for service connection for an immunological disability, which is being remanded. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are "inextricable intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). Additionally, the Board notes that in support of his claims for service connection for sinusitis and a breathing disorder, the Veteran submitted several medical statements that associate the claimed disorders with service. In a 2008 statement Dr. Varraux noted diagnoses of a sinus condition, breathing condition and joint pain, which as likely as not could be related to military service. Specifically, exposure to jet fuel and combustion fumes helped to aggregate his airways helping to precipitate his symptoms. In April 2016 a physician opined that the Veteran's COPD was due, in part, to exposure to jet fuel for 35 years, as well as smoking for 40 years. The private opinion reports are not accompanied by adequate rationale. Although VA examinations were obtained pertaining to the Veteran's sinus and respiratory disorders, the examiners did not address the Veteran's contentions that said disabilities were due to exposure to environmental hazards in service. On remand, an addendum opinion should be obtained. With respect to the claim for service connection for hypertension, in 2008 Dr. Varraux attributed the Veteran's hypertension to military service, including exposure to jet fuel and combustion fumes. This evidence reaches the low threshold for triggering VA's duty to provide the Veteran with a medical examination, which has not yet occurred. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). On remand, the Veteran should be afforded a VA examination to address the etiology of the Veteran's hypertension. Finally, the Veteran reported onset of a mental health disorder in service. The evidence of record shows diagnoses and treatment for anxiety disorder and depression related to medical problems. In light of the current depression and anxiety disorder diagnoses, as well as the Veteran's statements concerning onset and continuity of psychiatric symptomatology since service, the Board finds a remand is warranted to obtain a VA mental health examination that addresses the relationship, if any, between the claimed psychiatric disorder and service and/or a service-connected disability. On remand, relevant ongoing VA treatment records should also be obtained. Accordingly, the case is REMANDED for the following action: 1. Contact any appropriate sources to confirm whether the Veteran was exposed to ionizing radiation during duty as a security policeman while stationed at Ellsworth Air Force Base from January 1974 to December 1976, and if so, to determine a dose estimate. Also, request a copy of the Veteran's Record of Occupational Exposure to Ionizing Radiation (DD Form 1141) from any appropriate source. 2. Contact the Veteran and ask that he provide the names, addresses and approximates dates of any outstanding VA and non-VA health care providers who have treated him for the disabilities on appeal. After securing the necessary releases, the AOJ should undertake reasonable efforts to obtain any record adequately identified by the Veteran, which are not already of record. 3. The Veteran should be afforded an appropriate VA examination in order to determine the current nature and etiology of his immunological disorder diagnosed as subclass 1 of IgA immunoglobulin. The claims file must be made available to and be reviewed by the examiner. Any indicated evaluations, studies, and tests should be conducted. Thereafter, the examiner is asked to furnish an opinion with respect to the following questions: The examiner should offer an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the diagnosed subclass 1 of IgA immunoglobulin had its onset during service, or is otherwise related any aspect of the Veteran's service, including claimed exposure to radiation, herbicide, or other environmental hazard, including contaminated groundwater and inhalation of jet fuel and combustion fumes. Specifically, the examiner should address the service treatment records in March and April 1977 reflecting urinalysis with elevated white blood cell counts, and discuss whether these medical findings were early manifestations, or led to the development, of any current immunological disorder. The examiner must provide a complete rationale for all opinions and conclusions reached. 4. Return the claims file to the physician who prepared the March 2016 respiratory examination, if available, for an addendum opinion that addresses whether the Veteran's sinusitis and respiratory disorder, including asthma, is due to any aspect of the Veteran's service. If the original physician is not available, the claims file should be forwarded to a physician of similar or greater qualifications to provide the requested opinions. Following review of the claims file, the physician should provide an addendum opinion addressing whether it is at least as likely as not (50 percent or greater probability) that the Veteran's sinusitis and a respiratory disorder, including asthma, had its onset during service, or are otherwise related any aspect of the Veteran's service, including claimed exposure to jet fuel and combustion fumes. In formulating the opinion, the examiner is asked to comment on the 2008 medical opinion statement from Dr. Varraux. The examiner must provide a complete rationale for all opinions and conclusions reached. 5. Schedule the Veteran for a VA examination to determine whether the Veteran's hypertension is due to service. The claims file must be made available to and be reviewed by the examiner. Any indicated evaluations, studies, and tests should be conducted. Thereafter, the examiner is asked to determine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's hypertension had its onset in service, or is otherwise related any aspect of the Veteran's service, including claimed exposure to radiation, herbicide, or other environmental hazard, including contaminated groundwater and inhalation of jet fuel and combustion fumes. In formulating the opinion, the examiner is asked to comment on the 2008 medical opinion statement from Dr. Varraux. The examiner must provide a complete rationale for all opinions and conclusions reached. 6. Schedule the Veteran for a VA psychiatric disability examination to determine whether any current psychiatric disorder is related to military service. The claims file must be made available to and be reviewed by the examiner in conjunction with the examination. Following review of the claims file and examination of the Veteran, the examiner should identify all psychiatric disorders, to include depressive disorder and anxiety disorder. For each currently diagnosed acquired psychiatric disorder, the examiner should offer an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any such disorder had onset or is otherwise related to the Veteran's military service or a service connected disability. In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements regarding the incurrence of his claimed acquired psychiatric disorder and the recurrence of symptomatology. The rationale for any opinion offered should be provided. 7. Review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. 8. Then, readjudicate the Veteran's claim on appeal. If the benefits sought on appeal remain denied, the Veteran and her representative should be provided a supplemental statement of the case. Allow an appropriate period of time for response. 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). ______________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs