Citation Nr: 1634462 Decision Date: 09/01/16 Archive Date: 09/09/16 DOCKET NO. 12-05 858 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a reactive/autoimmune disease (AID), to include Sjogren's syndrome, fibromyalgia and reactive arthritis (RA) claimed as due to herbicide exposure, influenza vaccinations and service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a skin disorder (other than residual scars, sebaceous cysts and porphyria cutanea tarda (PCT)), originally claimed as chloracne, to include as due to herbicide exposure. 3. Entitlement to service connection for a liver disorder, claimed as secondary to a reactive/AID and herbicide exposure. 4. Entitlement to service connection for a prostate disorder, to include as due to herbicide exposure. 5. Entitlement to service connection for peripheral neuropathy of the right lower extremity, claimed as secondary to service-connected residuals of a fracture of the right heel and herbicide exposure and synovial cyst of the thoracic spine. 6. Entitlement to service connection for peripheral neuropathy of the left lower extremity, claimed as due to a reactive/AID disorder and herbicide exposure and synovial cyst of the thoracic spine. 7. Entitlement to service connection for peripheral neuropathy of the right upper extremity, claimed as due to a reactive/AID and herbicide exposure and synovial cyst of the thoracic spine. 8. Entitlement to service connection for peripheral neuropathy of the left upper extremity, claimed as due to reactive/AID and herbicide exposure and synovial cyst of the thoracic spine. 9. Entitlement to service connection for PCT. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and N. M., spouse ATTORNEY FOR THE BOARD Carole Kammel, Counsel INTRODUCTION The Veteran served on active duty in the United States Air Force (USAF) from November 1965 to May 1969. He served in the Republic of Vietnam (RVN) from December 3, 1968 to April 6, 1969. These matters are before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) located in Montgomery, Alabama. By that rating action, the RO denied service connection for the disabilities on appeal. The Veteran appealed this rating action to the Board. In June 2013, the Veteran and his spouse, N. M. testified at a video conference hearing before the undersigned; a transcript of that hearing has been associated with the Veteran's Virtual VA electronic record. At the hearing, the Veteran submitted an April 2011 report, prepared by J. C., M. D., in support of his claim for service connection for an AID, to include Sjogren's syndrome, along with a waiver of initial RO consideration. Thus, a remand to have the RO initially consider this evidence in the first instance is not necessary. 38 C.F.R. § 20.1304 (2015). A remand, however, is necessary for reasons that are outlined in the Remand section that follows the Introduction. The Veteran testified that he had a liver disorder, which was secondary to an AID. (Transcript (T.) at page (pg.) 12)). In addition, he maintained that his peripheral neuropathy of the right lower extremity was secondary to his service-connected residuals of a right heel fracture (e.g., broken heel bone) and that his peripheral neuropathy of the left lower extremity and right and left upper extremities were secondary to an AID. (Id. at pages (pgs.) 14, 15)). Prior to the hearing, and in a June 2010 statement to VA, the Veteran maintained that his peripheral neuropathy of the bilateral upper and lower extremities were secondary to a synovial cyst of the thoracic spine. (See VA Form 21-4138, Statement in Support of Claim, received by the RO in June 2010). Thus, the Board has recharacterized the claims for service connection for these disabilities as noted on the title page in order to reflect the Veteran's various contentions. During the hearing, the Veteran testified that his AID was secondary to herbicide exposure and influenza vaccinations. (T. at pg. 4). In a May 2011 statement to VA, the Veteran also maintained that his Sjogren's syndrome was secondary to his PTSD. (See VA Form 21-526(b), Veteran's Supplemental Claim, received by VA in May 2011). The RO has awarded service connection for PTSD. (See September 2011 rating action.) Thus, the Board has recharacterized the claim for service connection for an AID, to include Sjogren's syndrome, fibromyalgia and RA, to include as secondary to PTSD, as reflected on the title page. Concerning all the claims on appeal, and upon further review of the record, the Board notes that the RO addressed the theory of herbicide exposure in analyzing each claim in the January 2012 Statement of the Case. Thus, the Board has recharacterized each claim to reflect this theory of service connection as noted on the title page. Regarding the Veteran's claim for service connection for a skin disorder, the Veteran originally claimed service connection for chloracne. The evidence of record shows that he has been diagnosed with several skin disabilities, such as seborrheic keratosis and psoriasiform spongiotic dermatitis. (See reports, prepared by Skin Pathology Associates, dated in December 2003 and December 2008). While on appeal, the United States Court of Appeals for Veterans Claims (Court) addressed a case involving the scope of filed claims. In Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Court held that a claim is not limited to the diagnosis identified by the veteran. More precisely, a claim is for a disability that may reasonably be encompassed by several factors including: (1) the claimant's description of the claim; (2) the symptoms the claimant describes; and (3) the information the claimant submits or that [VA] obtains in support of the claim. As such, the Veteran's claim for service connection for a skin disorder has been recharacterized to broaden its scope. In addition, as service connection has been established for residual scars, sebaceous cysts, and the Veteran filed a notice of disagreement with an August 2015 rating action, wherein the RO denied service connection for PCT, the claim for service connection for a skin disorder includes all diagnosed skin disabilities other than these disabilities. In December 2014, the Board remanded the appeal to the RO for additional development. The requested development has been completed and the appeal has returned to the Board for further appellate review. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required on his part. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159 (2015). In addition, where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268, 271 (1998). I. Procedural Development The Board notes that in the explanatory section of its December 2014 remand, it noted that the Veteran had not been provided notice of the information and evidence needed to substantiate a claim for secondary service connection under 38 C F R § 310 (2015); Allen v Brown 7 Vet App 439 (1995). The Board, however, did not request this procedural development in the indented directive paragraphs. Thus, this should be accomplished upon remand. II. Substantive Development i) VA treatment records In March 2016, the Veteran was hospitalized at a VA facility for nausea, vomiting and dehydration. (See document labeled, "VAMC Report of Hospitalization" and received into the electronic record on March 25, 2016.) The complete hospitalization report, however, has not been associated with the Veteran's Benefits Management System (VBMS) electronic record. As the contents of the hospitalization report might contain clinical findings as to the etiology of the claimed disabilities on appeal, it is potentially relevant to all claims. Thus, on remand, the March 2016 VA hospitalization report, along with any nurses' and doctors' notes and associated treatment records, should be obtained and associated with the Veteran's VBMS electronic record. 38 U.S.C.A. § 5103A(c); 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). ii) Stegall Concerns-Reactive/AID Claim The Veteran seeks service connection for a reactive disease and/or AID. As noted in the Introduction, the Veteran has maintained that his AID is secondary to his presumed in-service herbicide exposure, influenza vaccinations and service-connected PTSD. In December 2014, the Board remanded this claim to obtain an etiological opinion, to include a determination of whether any diagnosed AID, such as Sjogren's syndrome, was etiologically related to his presumed herbicide exposure and in-service influenza vaccinations received in October 1968 and February 1969. Thereafter, VA examined the Veteran in March and May 2015, and diagnosed him with Sjogren's syndrome, fibromyalgia and seronegative inflammatory arthritis (i.e, RA). (See March 2015 VA Autoimmune and Fibromyalgia examinations and May 2015 medical opinion). After a review of the evidence of record and physical evaluation of the Veteran, the March 2015 VA nurse practitioner (NP) opined, in part, that it was not as likely at the Veteran's AID (Sjogren's Syndrome ) had its onset during military service or was etiologically related to the Veteran's presumed exposure to Agent Orange. The VA NP's rationale was that it was not one of the presumptive diseases subject to herbicide exposure [per VA guidelines.] (See March 2015 VA AID examination report). Neither the March 2015 VA NP, who also conducted the March 2015 VA fibromyalgia examination, nor the May 2015 physician, provided opinions as to the relationship between the Veteran's diagnosed fibromyalgia and RA and his presumed Agent Orange exposure, respectively. (See March 2015 VA AID and Fibromyalgia examination reports). The Board finds that the March 20153 VA NP's opinion, as it relates to the Veteran's Sjogren's syndrome and its relationship to his presumed Agent Orange exposure, is inadequate in evaluating the claim. The fact that service connection is not available on a presumptive basis because the diagnosed condition is not on the presumptive list does not preclude a veteran from establishing direct service connection, with proof of actual or direct causation. Polovick v. Shinseki, 23 Vet. App. 48, 52-53 (2009); see Stefl v. Nicholson, 21 Vet.App. 120, 123 (2007). Congress authorized the Secretary to "'prescribe regulations providing that a presumption of service connection is warranted for [a] disease' when a positive statistical association exists between Agent Orange exposure and the occurrence of [the] disease in humans." Polovick, 23 Vet. App. at 53 (quoting 38 U.S.C. § 1116(b)(1). However, in claims involving direct service connection based on herbicide exposure, other factors may affect the analysis, such as "whether a medical professional finds studies persuasive, whether there are other risk factors that might be the cause of the condition for which benefits are sought, and whether the condition has manifested itself in an unusual manner." Id. In formulating their respective opinions, it appears that the VA clinicians relied on the Institute of Medicine of the National Academy of Sciences (NAS) report to provide a negative linkage opinion. This is the report VA uses to establish which diseases should be presumptively service connected. 38 U.S.C. § 1116(2) ("In making determinations for the purpose of this subsection, the Secretary shall take into account ... reports received ... from the National Academy of Sciences "), (3); see Agent Orange Act of 1991, Pub.L. No. 102-4, § 2, 105 Stat. 11, 12 (1991); 58 Fed. Reg. 29,107, 29,108 (May 19, 1993). As the Court held in Polovick: "To [deny] service connection ... on the basis that it is not likely there is any nexus to service solely because the statistical analysis does not support presumptive service connection, would, in effect, permit the denial of direct service connection simply because there is no presumptive service connection." 23 Vet. App. at 55. Accordingly, the Board finds that the March 2015 VA physician should provide an addendum opinion as to the Agent Orange theory of the Veteran's diagnosed Sjogren's Syndrome and fibromyalgia that takes into account the Veteran's personal circumstances and/or how the recognized risk factor(s) apply to these disabilities. Regarding the relationship between the Veteran's diagnosed Sjogren's syndrome and his in-service influenza vaccinations, the March 2015 VA NP opined, after a recitation of the pertinent factual evidence of record, that it was not as likely that they were etiologically related because there was insufficient evidence. The VA NP's opinion is essentially unresponsive to the Board's question and contained no rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (a medical opinion that contains only data and conclusions is not entitled to any weight). In addition, the March 2015 VA NP did not provide any opinion as to the relationship between the in-service influenza vaccinations and the diagnosed fibromyalgia. Thus, these deficiencies must be addressed by the March 2015 VA NP in an addendum opinion. In May 2015, a VA physician diagnosed the Veteran with RA and opined that it was not the result of his influenza vaccinations. The VA physician reasoned that the Veteran had had follow-ups post-service with local doctors for several gastrointestinal ailments, had undergone an endoscopy and had been found to have had an allergic reaction to a hepatitic vaccination in 2003. (See May 2015 VA opinion). The VA physician's opinion is essentially unresponsive to the Board's December 2014 remand directives and contained no rationale. Id. In addition, the VA physician did not provide any opinion as to the relationship between the Veteran's diagnosed RA and his presumed in-service Agent Orange exposure. Thus, these deficiencies must be addressed by the May 2015 VA physician in an addendum opinion. iii) VA examination-AID, secondary to service-connected PTSD As noted in the Introduction, in a May 2011 statement to VA, the Veteran maintained that his diagnosed Sjogren's syndrome was secondary to PTSD. (See VA Form 21-526(b), Veteran's Supplemental Claim, received by VA in May 2011). The Veteran has been awarded service connection for PTSD. (See September 2011 rating action). Thus, the Board finds that the Veteran should be scheduled for a VA examination to determine whether any AID, notably his diagnosed Sjogren's syndrome, has been caused or aggravated (permanently worsened) by his PTSD. 38 C.F.R. § 3.310; Allen, supra; McLendon v. Nicholson, 20 Vet. App. 79 (2006). iv) VA examinations-Liver and Prostate Disorders The Veteran seeks service connection for liver and prostate disorders. As noted in the Introduction, the RO analyzed these claims, in part, on a theory of herbicide exposure in its January 2012 Statement of the Case. The Veteran's service personnel records reflect that he served in the RVN from December 3, 1968 to April 6, 1969. Thus, his exposure to Agent Orange is presumed. 38 C.F.R. § 3.307(a)(6) (2015) . The diseases subject to presumptive service connection as due to Agent Orange exposure include the following: AL amyloidosis, chloracne or other acneform disease consistent with chloracne, type 2 diabetes, Hodgkin's disease, ischemic heart disease (including, but 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), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, early-onset peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e) (2015). Changes were to the regulation for presumptive service connection for veterans shown to have been exposed to Agent Orange. See 78 Fed. Reg. 54763 (September 6, 2013); 38 C.F.R. § 3.309(e). These changes replaced the term "acute and subacute peripheral neuropathy" with the term "early-onset peripheral neuropathy." VA also removed Note 2 to § 3.309(e), which had required, in order for the presumption to apply, that the neuropathy be transient and appear within weeks or months of exposure to an herbicide agent and resolve within two years of the date of onset. Under the amendments, peripheral neuropathy will still need to become manifest to a degree of 10 percent or more within one year after the date of last exposure to herbicides in order to qualify for the presumption of service connection, but it no longer needs to be transient. However, a presumption of service connection based on exposure to herbicides is not warranted for any condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See 68 Federal Register 27630-27641 (May 20, 2003). Notwithstanding the foregoing, the United States Court of Appeals for the Federal Circuit has determined that a claimant is not precluded from establishing service connection for disability due to Agent Orange exposure with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). The Veteran's service treatment records (STRs) are devoid of any subjective complaints or clinical findings relating to any liver or prostate disabilities. A May 1969 service discharge examination report reflects that the Veteran's liver and prostate were evaluated as "normal." On an accompanying Report of Medical History, the Veteran denied having had any liver or stomach trouble or jaundice. Post-service treatment records reflect that the Veteran has been diagnosed as having benign prostate hypertrophy (BPH). (See VA Problem List, labeled as "CAPRI" and received into the Veteran's electronic record on July 9, 2015.) A liver disorder has not been diagnosed. The Veteran has not been afforded a VA examination to determine whether his diagnosed prostate disorder, BPH, or any currently present liver disorder are etiologically related to his presumed in-service herbicide exposure. In light of his presumed Agent Orange exposure and his current diagnosis of BPH, as noted above, the Veteran should be accorded a VA examination to address the etiology of his BPH, as well as any present liver disorder, to include their relationship, if any, to his presumed Agent Orange exposure. 38 C.F.R. § 3.327 (2015); McLendon, supra. iv) Service connection for PCT - Statement of the Case The Veteran timely disagreed with the August 2015 rating decision which denied service connection for PCT. The AOJ has not yet issued a statement of the case pertaining to this issue. The Board is required to remand, rather than refer, such issues to the AOJ, pursuant to Manlincon v. West, 12 Vet. App. 238 (1990). Accordingly, the case is REMANDED for the following action: 1. Send the Veteran a corrective VCAA notice that addresses the requirements for secondary service connection claims in accordance with 38 C.F.R. § 3.310. This notice must also inform the Veteran of which information and evidence, if any, that he is to provide to VA and which information and evidence, if any, that VA will attempt to obtain on his behalf. 2. Obtain a complete copy of the Veteran's March 2016 VA hospitalization report for nausea, dehydration and vomiting, along with any doctors' and nurses' notes and associated clinical records. Any records obtained must be associated with the Veteran's VBMS electronic record. All attempts to procure records should be documented in the Veteran's VBMS electronic record. If the AOJ cannot obtain records identified by the Veteran, notations to that effect should be inserted into the record. The Veteran and his representative are to be notified of unsuccessful efforts in this regard, in order to allow the Veteran an opportunity to obtain and submit those records for VA review. 3. Obtain addendum medical opinions from the March 2015 VA NP and May 2015 VA physician who provided opinions that addressed the etiology of the Veteran's Sjögren syndrome and fibromyalgia (March 2015) and RA (May 2015) (or, if unavailable, from another medical professional with appropriate expertise). The Veteran's electronic records, including a copy of this remand, must be made available to the above-cited clinicians for review of pertinent documents therein. A notation to the effect that this review has taken place should be made in the evaluation report. The March 2015 VA NP and May 2015 VA physician, or other reviewing clinician, is requested to review the record, and provide responses to the following questions as it relates to their diagnosed disability: Sjogren's syndrome and fibromyalgia (March 2015 VA NP) and RA (May 2015 VA physician): a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed Sjogren's syndrome, fibromyalgia and RA are causally related to the Veteran having received influenza vaccinations during military service in October 1968 and February 1969? The March 2015 VA NP and May 2015 VA physician, or other reviewing clinician, must provide reasons for each opinion given; a mere recitation of the facts is not sufficient. If the March 2015 VA NP and May 2015 VA physician, or other clinician, are unable to provide their respective opinion without resort to speculation, they should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The absence of evidence of treatment for Sjogren's syndrome, fibromyalgia and RA, or clinical findings indicative thereof, in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. b.) The March 2015 VA NP and, May 2015 VA physician, or other qualified clinician, must indicate whether it is at least as likely as not (50 percent or greater probability) that the Veteran's Sjogren's syndrome and fibromyalgia (March 2015 VA NP) and RA (May 2015 VA physician) are etiologically related to the Veteran's presumed exposure to Agent Orange based on his Vietnam service. In providing this opinion, the March 2015 VA NP and May 2015 VA physician, or other qualified reviewing clinician, may not rely solely on the fact that the diagnosed Sjogren's syndrome, fibromyalgia and RA are not on the presumptive list of diseases associated with herbicide exposure, or that the National Academy of Sciences may have determined that current studies do not support a statistical association between a given disease and herbicide exposure. Rather, the opinions must explain why any statistical or medical studies are found to be persuasive or unpersuasive, and should address any other considerations that the March 2015 VA NP and May 2015 VA physician, or other qualified reviewing physician, finds relevant, such as whether there are other risk factors for the development of the above-cited disorders or whether they have manifested in an unusual manner, among any other factors deemed pertinent. In addition, in providing the opinion, the March 2015 VA NP and May 2015 VA physician, or other qualified reviewing clinician, must take into account the Veteran's personal circumstances and how the recognized risk factor(s) apply in his particular case. c.) If and only if, the March 2015 VA NP and/or May 2015 physician, or other qualified clinician determines that either the Veteran's Sjogren's syndrome, fibromyalgia and/or RA are related to service, should he or she provide the following opinions: Is it at least as likely as not (i.e., 50 percent or greater probability) that any diagnosed liver disorder; peripheral neuropathy of the bilateral upper extremities and peripheral neuropathy of the bilateral lower extremities is/are proximately due to or aggravated (permanently worsened beyond the natural progress of the disorder) by the Sjogren's syndrome, fibromyalgia and/or RA? For any aggravation found, the March 2015 VA NP and/or May 2015 physician, or other qualified reviewing clinician, should state, to the best of his or her ability, the baseline of symptomatology and the amount, quantified, if possible, of aggravation beyond the baseline symptomatology. 4. Schedule the Veteran for examinations by a mental health clinician, or other appropriate clinician, to ascertain whether the Veteran's AID, currently diagnosed as Sjogren's syndrome, fibromyalgia and RA, have been caused or aggravated by his PTSD. The Veteran's electronic record must be provided to the examiner for review of pertinent documents therein. The examiner must indicate that such a review was conducted. The examiner should elicit from the Veteran and record a complete clinical history referable to AID, diagnosed as Sjogren's syndrome, fibromyalgia and RA. The examiner is requested to respond to the following question: Is it at least as likely as not (50 percent or greater probability) that any AID, diagnosed as Sjogren's syndrome, fibromyalgia and RA, has been caused or aggravated by (permanently worsened beyond the natural progress of the disorder) by the service-connected PTSD? If it is determined that the Veteran's Sjogren's syndrome, fibromyalgia and/or RA, has/have been aggravated (permanently worsened) by the service-connected PTSD, the examiner should identify the baseline level of the specific disability and the degree of disability due to aggravation. 5. After any additional records are obtained pursuant to the development in directive one (1) and associated with the record, schedule the Veteran for VA examinations by qualified examiners to determine the nature and etiology of any currently diagnosed prostate and liver disorders found on examination. a. The Veteran's electronic records must be made available to and thoroughly reviewed by each examiner in connection with his or her respective examination, and each examiner must acknowledge such receipt and review in any report generated as a result of his or her examination. b. Each examiner must review the Veteran's statements, hearing testimony, service and post-service treatment records in conjunction with his or her respective examination. Any special diagnostic studies deemed necessary should be performed. c. After reviewing the record, examining the Veteran, and identifying all appropriate symptoms and diagnoses, each examiner must provide medical findings or opinions responsive to the following question with respect to their respective disability (i.e, liver and prostate disorder). d. For each prostate and liver disorder found on examination, is it as least as likely as not (50 percent or greater probability) that it had its onset during military service or is etiologically related thereto, to include the Veteran's presumed exposure to Agent Orange in the RVN or has been caused or aggravated by (permanently worsened beyond the natural progress of the disorder) by any AID, diagnosed as Sjogren's syndrome, fibromyalgia or RA? If it is determined that the Veteran's prostate and liver disorders, if any, has/have been aggravated (permanently worsened) by any AID, diagnosed as Sjogren's syndrome, fibromyalgia or RA, the examiner should identify the baseline level of the specific disability and the degree of disability due to aggravation. In providing the opinions, the examining clinicians may not rely solely on the fact that any diagnosed prostate and/or liver disorders may not be on the presumptive list of diseases associated with herbicide exposure, or that the National Academy of Sciences may have determined that current studies do not support a statistical association between a given disease and herbicide exposure. Rather, the opinions must explain why any statistical or medical studies are found to be persuasive or unpersuasive, and should address any other considerations that the examining clinicians find relevant, such as whether there are other risk factors for the development of any liver and/or prostate disorders or whether they have manifested in an unusual manner, among any other factors deemed pertinent. In addition, in providing the opinion, the examining clinicians must take into account the Veteran's personal circumstances and how the recognized risk factor(s) apply in his particular case. A complete rationale must be provided for all opinions expressed. If an examiner is unable to offer the requested opinion, it is essential that he or she offer a rationale for his or her conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 6. If and only if the March 2016 VA hospitalization report requested in directive one (1), or any other records that are obtained pursuant to this remand, are associated with the record and contain evidence of peripheral neuropathy of the right lower extremity, should the Veteran be scheduled for a VA examination to ascertain its etiological relationship to the service-connected residuals of a right heel fracture. It is imperative that the electronic record. The Veteran's electronic record should be reviewed m conjunction with the examination. Any medically indicated special tests should be accomplished, and all special tests and clinical findings should be clearly reported. Based on examination of the Veteran and review of the electronic record, the examiner should provide opinions responding to the following question: Is it at least as likely as not (a 50% or greater probability) that any currently diagnosed peripheral neuropathy of the right lower extremity is due to or has been aggravated (permanently worsened beyond natural progression) by the service-connected residuals of a right heel fracture'? If aggravation is found the examiner shall opine, if possible, as to (a) the baseline level of the peripheral neuropathy of the right lower extremity prior to the aggravation by the service-connected residuals of a right heel fracture and (b) the current level of disability. A complete rationale must be provided for all opinions expressed. If an examiner is unable to offer the requested opinion, it is essential that he or she offer a rationale for his or her conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. Jones, supra. 7 Issue a Statement of the Case with regard to the issues of service connection for PCT. Inform the Veteran that he must perfect his appeal if he desires appellate review. Thereafter, return this issue to the Board only if the appeal of the issue is perfected. 8. Then, the RO should readjudicate the claims. Readjudication of the above-cited claims should include consideration of all evidence added to the file since issuance of a May 2015 supplemental statement of the case (SSOC). If any benefit sought on appeal remains denied, the Veteran and his representative should be provided with an SSOC. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate review, if in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims 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). _________________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2015).