Citation Nr: 1603621 Decision Date: 02/03/16 Archive Date: 02/11/16 DOCKET NO. 06-09 380 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and dysthymic disorder with memory loss. 2. Entitlement to service connection for a neurological disorder, to include multiple sclerosis. 3. Entitlement to service connection for Lyme disease. 4. Entitlement to service connection for a heart disorder. 5. Entitlement to service connection for headaches. 6. Entitlement to service connection for a disability manifested by vertigo. 7. Entitlement to service connection for treatment purposes under 38 U.S.C.A. § 1702 for any acquired psychiatric disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. Fleming, Counsel INTRODUCTION The Veteran had active military service from July 1973 to February 1975 and from September 1986 to September 1991. He also had periods of Reserve service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 2005, April 2008, and February 2012 rating decisions by Regional Offices (ROs) of the Department of Veterans Affairs (VA). In the April 2005 rating decision, the RO in Cleveland, Ohio, denied the Veteran's claim for service connection for what it characterized as dysthymic disorder and memory loss. In the April 2008 decision, the RO in Philadelphia, Pennsylvania, denied the Veteran's claims for service connection for a heart disorder, a neurological disorder, Lyme disease, headaches, a disability manifested by vertigo, and PTSD. In the February 2012 decision, the RO in Pittsburgh, Pennsylvania, denied service connection for treatment purposes under 38 U.S.C.A. § 1702 for any acquired psychiatric disorder. (Jurisdiction over the claims is currently with the Pittsburgh RO.) The Veteran timely appealed, and in May 2010, the Board remanded the issue of entitlement to service connection for what it characterized as an acquired psychiatric disorder for further evidentiary development and adjudication. In that remand, the Board instructed the agency of original jurisdiction (AOJ) to obtain additional VA examination and then re-adjudicate the claim. The AOJ obtained VA examination in December 2011 and provided the Veteran a supplemental statement of the case (SSOC) in February 2012. In addition, the Board remanded the claims in August 2015 for a hearing before a Veterans Law Judge, which was conducted later that same month. Thus, there has been compliance with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that 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). The Board notes that the United States Court of Appeals for Veterans Claims (Court) has recently has held that, although an appellant's claim identified only a single diagnosed disorder, it cannot be a claim limited only to that diagnosis, but must rather be considered a claim for any disability that may reasonably be encompassed by several factors-including the claimant's description of the claim, the symptoms the claimant describes, and the information the claimant submits or that VA obtains in support of the claim. The Court reasoned that the appellant did not file a claim to receive benefits only for a particular diagnosis, but for the affliction (symptoms) his condition, however described, causes him. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Here, although the Veteran filed his claim seeking service connection for dysthymic disorder specifically, the Board notes that the record contains diagnoses of dysthymic disorder, PTSD, depression, and anxiety disorder during the claim period. The Board thus finds that, pursuant to Clemons, supra, the Veteran's service connection claim is more accurately classified as one for any acquired psychiatric disorder. See Clemons, 23 Vet. App. 1 (2009). The Veteran testified before the undersigned at a hearing at the RO in August 2015. A transcript of the hearing has been associated with the Veteran's claims file. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). REMAND The Board finds that additional evidentiary development is necessary before a decision can be reached on the Veteran's claims. Here, the Veteran contends that he has an acquired psychiatric disorder, a neurological disorder, Lyme disease, a heart disorder, headaches, and a disability manifested by vertigo that began in or are otherwise etiologically linked to his time in service. In particular, the Veteran contends that he first experienced symptoms of his claimed disorders while on active duty and that he currently experiences similar symptoms, which have been variously diagnosed as psychiatric disorders, a seizure disorder, dementia, Lyme disease, chronic brain syndrome, and cognitive impairment. He also contends that his currently diagnosed coronary artery disease is attributable to his time on active duty or to his claimed neurological disorder or Lyme disease. The Veteran's service treatment records reflect that he was seen on a walk-in basis in April 1991 for consideration of whether he had multiple sclerosis. At that time, the Veteran noted that he had a family history of the disability and had been experiencing episodes of muscle cramps and spasms, temporary visual field loss, and vertigo, as well as intermittent problems with memory, for the past two to three years. He was referred for MRI study, which revealed focal areas of signal abnormality that were read as possible demyelination, but further testing was negative and multiple sclerosis was "definitely ruled out" in June 1991. Instead, he was diagnosed at that time with "disorientation/disequilibrium" and decreased visual acuity; neurological examination was normal. During his Reserve service, he complained in November 1992 and again in August 1996 of leg cramps, but no abnormalities were found on medical examinations conducted on those occasions. Post-service treatment records dating from the Veteran's time in Reserve service reflect that he complained of headaches and dizziness in April 1995; at that time, CT scan was normal, and the diagnosis was migraine. He sought treatment for chest pain in February 1996, but a stress test was normal. He again sought treatment in May 1997 for chest pain, which was initially diagnosed as myocardial infarction, but following cardiac catheterization, a corrected diagnosis of coronary artery disease was assigned. He was again seen in October 1998 for complaints of chest pain, but no diagnosis was assigned at that time. He sought emergent treatment in January 1999 for a cut to his thumb, which he said occurred when he became lightheaded and fell into a saw. He was diagnosed at that time with near syncope, but a neurological etiology was considered "doubtful." He was again seen in June 1999 for complaints of "dizziness and giddiness"; at that time, Lyme disease was suspected, but no diagnosis was assigned. The Veteran was seen in February 2001 for what was identified as a third round of treatment for Lyme disease, which was noted to have first been diagnosed in January 2000. At an October 2001 follow-up visit, he was noted to be "approaching normal physical abilities" and was cleared for deployment pending completion of treatment. In June 2002, he reported experiencing symptoms of stiffness, difficulty with balance, confusion, and aphasia that resolved with each round of treatment but recurred when treatment was discontinued. At that time, multiple sclerosis as well as Alzheimer's disease had been ruled out, per the Veteran's report. He was seen in July 2002 for ongoing memory problems, which he stated had required him to take leave from his work as a pastor. His memory loss was found at that time not to disqualify him from Reserve service. An August 2002 neuropsychological assessment, the differential diagnosis was minimal cognitive impairment versus atypical depression. At that time, the examiner acknowledged the Veteran's recurrent treatment for Lyme disease, as well as his complaints of dizziness, memory lapses, confusion, and headaches, and the diagnosis of dysthymic disorder. The examiner noted that the Veteran's parishioners had remarked on his perceived memory lapses but found that no memory impairment was present, reasoning instead that any decrement in the Veteran's memory did not rise to the level of impairment, given his overall superior level of intellectual functioning. The Veteran was medically disqualified from Reserve service in February 2003 due to the "unpredictable effect that his medical condition has on his memory." The disorder was diagnosed at that time as, variously, dysthymic disorder with memory loss, and as dementia, depression, and a neurologic disorder. In December 2003, a line-of-duty determination found the disorder to have existed prior to service. However, a second line-of-duty determination conducted in September 2005 recommended a finding of "in the line of duty." In so finding, the evaluator reasoned that the symptoms the Veteran reported in 2003 were similar to those he complained of in 1991, while still on active duty, and "no credible evidence exists to contradict this opinion." The Veteran underwent neurological evaluation in March 2002. At that time, he reported headaches and memory dysfunction, which he stated began around 2000. He reported having been bitten by a tick during a camping trip in 1993 or 1994 that led to a bull's-eye lesion and a diagnosis of Lyme disease in 2000, although he stated that symptoms related to the Lyme disease had resolved. The neurologist stated that "given lack of lesions," he was "unable to account for the memory disturbance based on his Lyme disease." At a follow-up visit in August 2002, the neurologist stated that neuropsychological evaluation had failed to show any evidence of dementia, although he had experienced seizure symptoms following a new medication. The neurologist stated that he "remain[ed] perplexed by his syndrome" in October 2002 and stated the following month that he was "unable to show evidence of a neurologic disease . . . evidence of a cognitive impairment was not shown." The Veteran subsequently underwent evaluation by a second neurologist in December 2002, who noted his main complaint of memory problems that had begun approximately two years prior. That neurologist noted that the Veteran had been seen in 1991, while still on active duty, for similar complaints of balance problems. The Veteran reported at the evaluation that he had been bitten by a tick in 1996 during a camping trip and had been diagnosed in 2000 with Lyme disease following symptoms of muscle cramping and aches, balance problems, and memory difficulties. Further testing for Lyme disease was negative, although the neurologist noted that his symptoms had resolved following treatment for Lyme disease. No diagnosis was assigned at the evaluation. The Veteran had a follow-up visit later in December 2002, at which time he underwent neuropsychiatric assessment and was diagnosed with mild cognitive impairment "which would be borderline for any dementia syndrome." The neurologist concluded that the "pattern of deficits, however, point mostly to subcortical area dysfunctioning" of undetermined etiology. Pursuant to his application for Social Security Administration benefits, the Veteran underwent psychiatric evaluation in May 2003, at which time he was diagnosed with dementia. In September 2003, he was again seen by a neurologist, who diagnosed mild cognitive impairment and borderline dementia syndrome with "a pattern of deficits pointing mostly to subcortical area dysfunctioning thought to be possibly related to a central nervous system inflammatory and/or post infectious syndrome." The neurologist noted that the Veteran had had a tick bite in 1996 and been diagnosed with Lyme disease in 2000, but that later testing had been negative for any specific inflammatory or post-infectious syndrome. He complained of short-term memory loss, muscle cramps, and headaches. At a September 2004 visit to the same neurologist, the Veteran reported similar symptoms and was again diagnosed with mild cognitive impairment and borderline dementia that was found to "point mostly to subcortical area dysfunction." The neurologist submitted letters in April 2004 and July 2006 in which he stated that he was treating the Veteran for "dementia syndrome, seizures, and headaches." In April 2004, the neurologist stated that the Veteran's dementia was "due to an unknown cause but thought to be related to central nervous system inflammatory syndrome." In July 2006, the neurologist further diagnosed cognitive impairment due to neurological disability. At later treatment visits in 2012 and 2013, diagnoses of coronary artery disease, seizure disorder, depression, and dementia with memory loss were assigned. The Veteran underwent VA psychiatric examination in February 2005. At that time, he reported a history of seizure disorder, headaches, and dysthymia, as well as a diagnosis of dementia syndrome. He stated that he had been diagnosed with Lyme disease in 2000, although he claimed that he "probably acquired" the disease while assisting at a plane crash site during Reserve service. He reported symptoms of confusion, difficulty finding words, fatigue, and headaches that had continued since before his retirement from Reserve service. He stated that he was unable to work as a pastor due to the severity of his symptoms. Mental status examination revealed some problems with short-term memory as well as irritability and sadness. The examiner diagnosed dementia and dysthymia, with an additional rule-out diagnosis of depressive disorder. No etiological opinion was provided. At a second VA psychiatric examination conducted in April 2006, the Veteran reported that his mental health difficulties had begun during active duty following three funerals for children that he had been required to conduct as chaplain and the suicide of an individual he had counseled. He reported symptoms of feeling overwhelmed and guilty, as well as lack of energy and motivation and difficulty with concentration and memory. He stated that he had retired due to his poor memory. The examiner diagnosed depression and dementia, with a rule-out diagnosis of pseudodementia secondary to depression, and opined that the Veteran's difficulty with memory could be attributable either to the depression or to ischemic vascular damage noted in a 2004 MRI. Again, no etiological opinion was offered, although the examiner recommended that a neuropsychological evaluation be conducted to clarify the Veteran's diagnoses and symptoms. The Veteran again underwent VA examination in December 2011. At that time, he stated that during his first period of service he heard his friends who had died in Vietnam talking to him at night. He also said he dealt with family members of individuals whom he had counseled who had committed suicide. Although he identified these as stressors, the examiner found that there had been "no specific traumatic events of any kind during his first tour of service." He stated that he left service the first time because of the voices he was hearing but that those symptoms abated once he was out of service. He stated that the voices began again during his second period of service, following incidents in which a sailor committed suicide and three children died, and continued to recur occasionally. The examiner found these experiences to be "dreams or hypnagogic illusions" that "do not appear to be psychotic in nature." Further, despite the Veteran's complaints of confusion and memory loss, his scores on mental status examination were "perfectly average for his age and education level" and showed no memory, concentration, or cognitive impairment. The examiner diagnosed dysthymic disorder only, finding that its onset was at the Veteran's retirement from his work as a pastor, not during either period of service. In so finding, the examiner stated that the Veteran "appeared to do well in his job, with no difficulties of any kind up until his retirement," and found no etiological relationship between his in-service symptoms and his current disability. At a May 2012 VA neurological examination, the examiner stated that the Veteran had been diagnosed with Lyme disease in 1996, as well as with memory problems and headaches in 1991. The Veteran reported that he had experienced trouble with memory and concentration, along with headaches, depression, and dizziness, in the late 1980s that "temporally correlated with delusions and hallucinations that deceased war friends were contacting him." The examiner also noted that multiple MRIs beginning in 1991 had shown stable small white matter T2 hyperintensities. Upon review of the Veteran's symptoms, the examiner found that the Veteran did not have depression, cognitive impairment, dementia, or any other mental health disorder attributable to central nervous system disease. Rather, the examiner found that the Veteran's depression caused his reported cognitive problems; no evidence for multiple sclerosis or progressive demyelinating disease was found. The examiner specifically concluded that there "remains no strong evidence that the Veteran has a central nervous system inflammatory condition," based on multiple negative testing, unremarkable examination, and "no progression over time." The Veteran also submitted a private psychological evaluation conducted in December 2013. At that time, he reported stressors of witnessing others being wounded and being exposed to dismembered bodies from a plane crash, as well as the suicide of a service member whom he had counseled. Mental status examination showed mild cognitive impairment, and the examiner diagnosed PTSD, major depressive disorder, and generalized anxiety disorder, which she appeared to link to his experiences in service. The Veteran and his representatives have submitted multiple statements in support of his claims, and the Veteran has testified before the undersigned Veterans Law Judge. In March 2006, the Veteran reported that he had worked at a crash site during Reserve service and was activated as a chaplain following September 11, both incidents he cited as leading to his current psychiatric difficulties. In October 2008, the Veteran contended that he had had a heart attack in service and that his current heart problems stem from that incident. He also contended that he contracted Lyme disease while on active duty and that symptoms of headache and vertigo began during service. The Veteran also identified multiple stressors for his claimed PTSD, including the death of many of his fellow Marines and his meetings with former prisoners of war during his first period of service, his work to recover remains following plane crashes during both periods of service, his service as a chaplain at a hospital where individuals died, the funerals of three children he conducted, and his work with six individuals who later committed suicide. He also claimed that he was chaplain at a location where "the danger of radiation exposure was extremely significant," which he also identified as a stressor. In addition, at his August 2015 hearing, the Veteran stated that he had been stationed at Camp Lejeune during his first period of service, raising the possibility that his reported symptoms are linked to exposure to contaminated water at that facility. In addition, he contended that he was exposed to herbicides that were sprayed at Camp Asaka, Japan, while he was stationed there. He further contended that he was exposed to radiation by way of being in aircraft that he was told were transporting nuclear weapons. He also reported that in September 1994, during a period of Reserve activation to deal with a plane crash, he believes he was bitten by a tick that he contended caused the Lyme disease that caused all his later symptoms. He further attributed his psychiatric symptoms to having seen the bodies of the crash victims during that time, as well as bodies of crash victims he worked with while stationed at Camp Asaka. During the hearing the Veteran also contended that his symptoms of headaches and vertigo began during active duty and have continued since that time. Applicable law provides that service connection will be granted for disability resulting from an injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303 (2015). That an injury or disease occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2015). Generally, establishing service connection requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Service connection on a secondary basis is warranted when it is shown that disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (2015). This includes disabilities aggravated or made chronically worse by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Pursuant to 38 U.S.C.A. §§ 1110, 1131 and 38 C.F.R. § 3.310(a), when aggravation of a Veteran's non-service-connected condition is proximately due to or the result of a service-connected condition, such Veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. See id. at 448. The National Research Council of the National Academies Committee on Contaminated Water released a report in 2009 indicating that the water supply systems at Camp Lejeune were contaminated with industrial solvents trichloroethylene (TCE) and perchloroethylene (PCE) from approximately 1957 to 1987. Benzene and vinyl chloride were also present in the water. In this regard, the Board notes that specific guidelines have been established for adjudicating claims based on exposure to contaminated drinking water in Camp Lejeune between 1957 and 1987. See VBA Training Letter 11-03 (April 27, 2011); see also M21-1, Part IV.II.1.H.32. Of note, the VBA Training Letter cites the 2009 findings from the National Research Council in which it was found that various disease conditions, including neurobehavioral effects, have a limited/suggestive association to certain contaminants found in water supplies at Camp Lejeune. The Veteran also contends that exposure to herbicides during his active military service caused his claimed disabilities, including coronary artery disease. In particular, he has stated that he was exposed to what he believes was Agent Orange or a similar type of hazardous chemical while engaging in "experimental processes" with the chemicals during his time at Camp Asaka in Japan and at Camp Lejeune in North Carolina. The Veteran has alternatively contended that exposure to ionizing radiation during service may have caused his claimed disabilities, and alleged that he may have been exposed to radiation while flying with what he was told were nuclear weapons during his time in Japan. The Board notes that the Veteran did not have any service in Vietnam during his period of military service, nor did he claim such service. See 38 C.F.R. § 3.307(a)(6)(iii). That, however, does not preclude the Veteran from establishing entitlement to service connection for coronary artery disease, or any other claimed disability, due to exposure to herbicides. The Veterans Benefits Administration Adjudication Manual (M21-1) provides a procedure for verifying exposure to herbicides in locations other that the Republic of Vietnam or along the demilitarized zone in Korea. See M21-1, Part IV, Subpart ii, Chapter 2, Section C, Subsection 10, Paragraph o. This procedure requires: (1) asking the Veteran for the approximate dates, location, and nature of the alleged exposure; (2) furnishing the Veteran's detailed description of exposure to Compensation Service for confirmation; and (3) requesting a review of the Department of Defense inventory of herbicide operations to determine whether herbicides were used as alleged. In this case, if Compensation Service's review confirms that herbicides were used as alleged, or that the Veteran was exposed to toxic or hazardous chemicals while at Camp Asaka or Camp Lejeune, then a determination must be made as to whether service connection is in order. If Compensation Service's review does not confirm that herbicides were used as alleged, then a request should be sent to the Joint Services Records Research Center (JSRRC) for verification of a claims exposure to herbicides or other chemicals. Here, however, the RO has not attempted to corroborate the Veteran's allegation of herbicide exposure at Camp Asaka or Camp Lejeune. Thus, in order to comply with the directives set forth in the M21-1, the case must be remanded for additional development, including by requesting confirmation of the use/storage of herbicides at Camp Asaka or Camp Lejeune from the National Personnel Records Center. The RO must also contact the Compensation Service, as directed by M21-1, IV.ii.2.C.10. o. If Compensation Service's review does not confirm herbicide exposure, the RO must then send a request to JSRRC for verification as to whether the Veteran was exposed to herbicide agents during his period of service, in accordance with the instructions set forth in M21-1, IV.ii.2.C.10. o. Turning to the claims of service connection as due to exposure to ionizing radiation, the record shows that the Veteran has contended that his disabilities were caused by exposure to ionizing radiation during military service because he was exposed to ionizing radiation while flying with what he was told were nuclear weapons while stationed in Japan. Service connection for conditions claimed to be due to exposure to ionizing radiation in service can be established in any of three different ways. See Hilkert v. West, 11 Vet. App. 284, 289 (1998); McGuire v. West, 11 Vet. App. 274, 277 (1998); Hardin v. West, 11 Vet. App. 74, 77 (1998); Rucker v. Brown, 10 Vet. App. 67, 71 (1997); Ramey v. Brown, 9 Vet. App. 40, 44 (1996), aff'd sub nom Ramey v. Gober, 120 F.3d 1239 (Fed. Cir. 1997). First, there are types of cancer that are presumptively service connected under 38 U.S.C.A. § 1112(c) (West 2014) based on participation in "radiation risk activities." Second, direct service connection can be established under 38 C.F.R. § 3.303(d) by "show[ing] that the disease or malady was incurred during or aggravated by service, a task which includes the difficult burden of tracing causation to a condition or event during service." Combee v. Brown, 34 F.3d at 1043. And third, service connection can be established under Section 3.303(d) with the assistance of the procedural advantages prescribed in 38 C.F.R. § 3.311 (2015), if the condition at issue is one of the "radiogenic diseases" listed in Section 3.311(b). The Board notes that the Veteran's diagnosed disabilities are not among those potentially entitled to presumptive service connection under 38 C.F.R. § 3.309(d)(2), nor are they identified as radiogenic diseases under 38 C.F.R. § 3.311. Moreover, he is not a radiation-exposed Veteran within the definition of the 38 C.F.R. § 3.309(d)(3)(ii)(A). Regardless, VA has a duty to confirm whether the Veteran was exposed to ionizing radiation during service as he could still establish service connection on a direct basis, including on the basis of exposure to radiation, pursuant to Combee v. Brown, 34 F.3d at 1043. Thus, on remand the Veteran should be asked to clarify his contentions with regard to his claim of exposure to radiation, to include requesting clarification about whether a dosimetry badge was issued and affording the Veteran an opportunity to more specifically identify the circumstances in which he believes he was exposed to radiation. If exposure to ionizing radiation is shown, the file should be referred to the Under Secretary for Benefits for further consideration of the claim of exposure to ionizing radiation pursuant to the procedures outlined in 38 C.F.R. § 3.311(c), (d), and (e), beginning with obtaining a radiation dose estimate from the Under Secretary for Health, which assessment is made based on the entire record, including personnel records. See 38 C.F.R. § 3.311(a)(2)(iii). Regarding the Veteran's claim for service connection for an acquired psychiatric disorder, insofar as that claim includes PTSD, the Board notes that, with the exception of the plane crash he claims to have worked while in the Air Force Reserve in 1994, the Veteran has not provided information sufficient to allow any searches to be made to corroborate his alleged stressors. Rather, he has reported to his VA treatment providers and to the December 2013 private psychiatrist that he was affected by plane crashes while stationed in Japan at which he was required to participate in recovery of remains, as well as by deaths and injuries to individuals he knew or counseled during service. Thus, on remand the AOJ must give the Veteran opportunity to provide sufficiently specific information concerning his identified stressors. Once any such information is received, the AOJ must prepare a report detailing each stressor and contact the JSRRC, and any other appropriate source(s), for verification of the claimed stressors. (The Board notes that the Veteran's service personnel records confirm that he was not in combat during active duty, nor has the Veteran contended that he was in combat or experienced any fear or hostile military or terrorist activity while on active duty.) The AOJ is reminded that requiring corroboration of every detail, including the Veteran's personal participation, defines "corroboration" far too narrowly. Suozzi v. Brown, 10 Vet. App. 307, 311 (1997). The records need only imply the Veteran's participation (e.g., not controvert the Veteran's assertion that he was present when the events the records establish that his unit experienced occurred). See also Pentecost v. Principi, 16 Vet. App. 124, 128-129 (2002). In Suozzi, the United States Court of Appeals for Veterans Claims (Court) held that a radio log showing that the Veteran's company had come under attack was new and material evidence to warrant reopening a claim of service connection for PTSD, despite the fact that the radio log did not specifically identify the Veteran's participation. Suozzi, 10 Vet. App. at 310. The Court also stressed that the evidence favorably corroborated the Veteran's alleged in-service stressor. Id. at 311. Reaffirming its holding in Suozzi, the Court stated in Pentecost that, although unit records did not specifically identify a Veteran as being present during rocket attacks, the fact that he was stationed with a unit that was present while such attacks occurred objectively corroborated his claim of having experienced rocket attacks. Pentecost, 16 Vet. App. at 128. Under relevant VA regulations, action should be taken to obtain a medical opinion if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or symptoms of disability; (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, which may be established by competent lay evidence; and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease. 38 C.F.R. § 3.159(c)(4) (2015). See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third prong of Section 3.159(c)(4), which requires that the evidence of record "indicate" that the claimed disability or symptoms may be associated with service, establishes a low threshold. The Board further notes that the Court has held that once VA undertakes the effort to provide an examination when developing a claim for service connection, even if not statutorily obligated to do so, it must provide an adequate one. See Woehlaert v. Nicholson, 21 Vet. App. 456, 464 (2007), citing Barr, 21 Vet. App. at 311; see also Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence . . . is essential for a proper appellate decision"). Here, however, the examinations to date have not provided a comprehensive diagnosis or diagnoses that account for all the Veteran's reported symptoms. In particular, it is not clear whether the Veteran-either currently or at any time during the appeal period-experiences Lyme disease, multiple sclerosis, or any other neurological, cognitive, or psychiatric disorder. It is further unclear whether the Veteran's symptoms of headaches and vertigo are due to separately diagnosable disabilities or are attributable to any Lyme disease, multiple sclerosis, or any other neurological, cognitive, or psychiatric disorder currently present. The examiners have further failed to fully address the Veteran's credible contentions concerning the in-service onset of symptoms of lack of balance, dizziness, and confusion. These symptoms are clearly documented in the Veteran's service treatment records and are similar to those for which he has been treated since 2000, but no examiner to date has clearly and comprehensively discussed whether the in-service occurrence of such symptoms represents an early manifestation of any Lyme disease, multiple sclerosis, or any other neurological, cognitive, or psychiatric disorder currently found to be present. The Board thus finds that there is insufficient competent medical evidence on file to make a decision and must therefore remand to obtain additional medical examination and nexus opinions regarding the etiology of the Veteran's claimed disorders. See 38 C.F.R. § 4.2 (2015) (where an examination report does not contain sufficient detail, it is inadequate for evaluation purposes); McLendon, 20 Vet. App. 79; see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (a medical examination report must contain clear conclusions with supporting data and a reasoned medical explanation connecting the two); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (a medical opinion must be supported by an analysis that the Board can consider and weigh against contrary opinions). Under these circumstances, evidentiary development is needed to fully and fairly evaluate the Veteran's claims of service connection for an acquired psychiatric disorder, a neurological disorder, Lyme disease, a heart disorder, headaches, and a disability manifested by vertigo. 38 U.S.C.A. § 5103A (West 2014). On remand, the Veteran must be provided with VA neurological examination with the goal of clarifying his diagnosis or diagnoses and determining what symptoms are attributable to which diagnosis, as well as whether each diagnosed disorder began in or is etiologically linked to the Veteran's service. Thus, the VA examiner-a qualified neurologist-must review the Veteran's claims file in its entirety, comprehensively examine the Veteran, and assign a diagnosis or diagnoses that together encompass all of the Veteran's reported symptoms that are found to be present. For each such disorder diagnosed, the examiner must opine as to whether the disorder is directly linked to the Veteran's time on active duty, to include his alleged tick bites, his claimed in-service stressors, and his claimed exposure to herbicide and radiation (if such exposure is confirmed pursuant to the development directed herein), as well as to his exposure to contaminated water at Camp Lejeune. The examiner must specifically discuss the Veteran's in-service treatment for complaints of confusion, memory and balance problems, and dizziness as well as his credible reports of having continued symptomatology from his time in service to the present. (If additional examination is required to complete these directives, such must be accomplished before the case is returned to the Board.) The examiner must also provide an opinion as to whether it is at least as likely as not that the Veteran's diagnosed coronary artery disease, as well as his claimed headaches and vertigo, was caused or worsened by any neurological or other disorder diagnosed above. Each opinion must be based upon consideration of the Veteran's documented history and assertions through careful consideration of all records in the claims file. Such opinions are needed to fully and fairly evaluate the claims of service connection. See 38 U.S.C.A. § 5103A(d) (West 2014). The Board further finds that the claim for service connection for treatment purposes under 38 U.S.C.A. § 1702 for any acquired psychiatric disorder is inextricably intertwined with the remaining claims and must thus also be remanded for further consideration by the AOJ. This is so because the outcome of the Veteran's claim for service connection for an acquired psychiatric disorder could impact his claim for entitlement to service connection for treatment purposes under 38 U.S.C.A. § 1702 for any acquired psychiatric disorder. As such, a Board decision on the 38 U.S.C.A. § 1702 issue at this time would be premature. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are inextricably intertwined when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). Thus, the 38 U.S.C.A. § 1702 claim must be remanded to the AOJ pending adjudication of the Veteran's claims for service connection. Accordingly, the case is REMANDED for the following action: Please note that this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested. 1. Send the Veteran and his representative a letter requesting that the Veteran provide sufficient information, and if necessary authorization, to enable any additional pertinent evidence not currently of record relating to the Veteran's claimed disabilities to be obtained. Explain the type of evidence that is the Veteran's ultimate responsibility to submit, including as relates to his claim of exposure to herbicides and to ionizing radiation. Among other things, ask the Veteran to identify all in-service exposure to ionizing radiation he experienced and to fill out an Exposure to Radiation Questionnaire, to include identifying the areas where he was allegedly exposed to radiation and why he believes he was exposed to radiation at those locations. The AOJ must also specifically ask the Veteran to provide information relating to his alleged in-service stressors, including specific dates. The Veteran should also be invited to submit any pertinent evidence in his possession. The AOJ must explain the type of evidence that is the Veteran's ultimate responsibility to submit. 2. Once the Veteran has provided sufficiently specific information, a letter must be prepared asking JSRRC to provide any available information that might corroborate the Veteran's alleged in-service stressors. JSRRC must be provided with a description of any alleged stressors properly identified by the Veteran, as well as copies of any relevant documents (e.g., the Veteran's DD Form 214, other service personnel records, and/or any statements made by the Veteran), or information contained therein. Any additional action suggested by JSRRC must be accomplished. 3. Complete the procedures provided in the Veteran's Benefits Administration Manual Part IV, Subpart ii, Chapter 2, Section C, Subsection 10, Paragraph o, for verification of the Veteran's claimed herbicide exposure. In particular, the AOJ must (1) ask the Veteran for the approximate dates, location, and nature of the alleged exposure; (2) furnish the Veteran's detailed description of exposure to Compensation Service for confirmation; and (3) request a review of the DOD inventory of herbicide operations to determine whether herbicides were used as alleged. If Compensation Service's review confirms that herbicides were used as alleged, or that the Veteran was exposed to toxic or hazardous chemicals while at Camp Asaka or Camp Lejeune, then the AOJ must determine whether service connection is in order. If Compensation Service's review does not confirm that herbicides were used as alleged, then the AOJ must request verification from JSRRC as to whether the Veteran was exposed to herbicide agents or other hazardous or toxic chemicals at Camp Asaka or Camp Lejeune as alleged during his first period of service (July 1973 to February 1975), in accordance with the instructions set forth in M21-1 IV.ii.2.C.10.o. All documentation sent and received by the AOJ must be associated with the claims file. 4. Conduct all necessary development of the Veteran's report of possible exposure to radiation. The AOJ should make any necessary determinations as to whether military records establish the Veteran's presence at a site at which radiation is claimed to have occurred. If it is determined, in accordance with 38 C.F.R. § 3.311(a)(4) that the Veteran was exposed to ionizing radiation, then, in accordance with 38 C.F.R. § 3.311(a)(2)(iii), forward the Veteran's records concerning his radiation exposure, including any service records and his statements and testimony regarding radiation exposure, to the Under Secretary for Health, for preparation of a dose estimate. (If a specific estimate cannot be made, a range of possible doses should be provided.) If more information from the Veteran is required regarding specifics of his alleged exposure, he should be contacted and asked to provide the information. 5. If the above-requested development results in a positive dose estimate or any range of possible doses, refer the claim to the Under Secretary for Benefits for consideration of the Veteran's claim of exposure to ionizing radiation pursuant to the procedures outlined in 38 C.F.R. § 3.311(c), (d), and (e). 6. Schedule the Veteran for a comprehensive VA neurological examination to determine the nature and etiology of his current disabilities as thoroughly and conclusively as possible. The claims file must be made available to, and reviewed by, the designated examiner. In particular, the examining neurologist must conduct a thorough records review and examination of the Veteran and must assign a diagnosis or diagnoses that together encompass all of the Veteran's reported symptoms that are found to be present. In rendering the diagnosis or diagnoses, the examiner must discuss the medical evidence laid out in detail above; the goal is to determine what disability or disabilities are causing the Veteran's current symptoms and to make sense of the multiple and varied diagnoses he has been assigned over the course of the appeal period. For each such disorder diagnosed, the examiner must provide an opinion as to whether it is at least as likely as not (i.e., there is at least a 50 percent probability) that the disorder is directly linked to the Veteran's time on active duty, to include his alleged tick bites, his claimed in-service stressors, and his claimed exposure to herbicide and radiation (if such exposure is confirmed pursuant to the development directed herein). The examiner must also consider the Veteran's documented history and his contentions, particularly those concerning his in-service exposure to contaminated water at Camp Lejeune. The examiner must specifically discuss the Veteran's 1991 in-service treatment for complaints of confusion, memory and balance problems, and dizziness as well as his credible reports of having experienced similar symptoms from his time in service to the present. The examiner must specifically discuss the Veteran's credible contentions concerning the in-service onset and continuity of symptoms, as described above. The examiner must further opine, for each diagnosed disorder, as to whether it is at least as likely as not that any such disorder is related to his in-service exposure to toxic chemicals while stationed at Camp Lejeune. (It is noted for the VA medical examiner that the water supply at Camp Lejeune was found to be contaminated with chemical compounds trichloroethylene, tetrachloroethylene, perchloroethylene, and benzene.) The examiner must further specifically address, in the context of any negative opinion, the NRC's 2009 findings that neurobehavioral effects have a limited/suggestive etiological relationship to such chemical exposure. The examiner must also provide an opinion as to whether it is at least as likely as not that the Veteran's diagnosed coronary artery disease, as well as his claimed headaches and vertigo, was caused or worsened by any neurological or other disorder diagnosed above. If additional examination is required to complete these directives, such must be accomplished before the case is returned to the Board. 8. After completing any additional notification and/or development deemed warranted, the claims on appeal must be adjudicated in light of all pertinent evidence and legal authority. If any benefit sought remains denied, the Veteran and his representative must be furnished a supplemental statement of the case and afforded the appropriate time for response before the claims file is returned to the Board. 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 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). _________________________________________________ JAMES L. MARCH 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).