Citation Nr: 1700382 Decision Date: 01/09/17 Archive Date: 01/18/17 DOCKET NO. 13-12 630 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for jungle rot of the bilateral feet. 2. Whether new and material evidence has been received sufficient to reopen a claim for tinea cruris of the groin. 3. Entitlement to service connection for posttraumatic stress disorder (PTSD). 4. Entitlement to service connection for tinea cruris of the groin. 5. Entitlement to service connection for a low back disability. 6. Entitlement to service connection for varicose veins of the left leg. 7. Entitlement to service connection for a kidney disability, to include renal failure, to include as due to exposure to herbicides. 8. Entitlement to service connection for a lung disability, to include as due to exposure to herbicides. 9. Entitlement to service connection for chronic obstructive pulmonary disease (COPD), to include as due to exposure to herbicides. 10. Entitlement to service connection for an acquired psychiatric disorder other than PTSD, to include depressive disorder. 11. Entitlement to a total disability rating due to individual unemployability (TDIU). REPRESENTATION Appellant represented by: Ralph J. Bratch, Attorney ATTORNEY FOR THE BOARD Michael Sanford, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1964 to March 1967 with service in the Republic of Vietnam. These matters come before the Board of Veterans' Appeals (Board) on appeal from multiple rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In a February 2010 rating decision, the RO denied service connection for PTSD. In a June 2011 rating decision, the RO denied service connection for lung problems and renal failure, as well as entitlement to a TDIU. In a November 2011 rating decision, the RO denied the application to reopen a claim for service connection for tinea cruris of the groin (jungle rot). In a June 2012 rating decision, the RO denied service connection for bilateral varicose veins with venous insufficiency and left leg ulcer and a low back disability. In his April 2013 substantive appeal (VA Form 9), the Veteran requested a hearing before a Veterans Law Judge. However, in a December 2015 motion, the Veteran withdrew his request for a Board hearing. See 38 C.F.R. § 20.704(e) (2015). During the pendency of the appeal, the Veteran changed his representative to Ralph J. Bratch, Attorney. The Board recognizes this change in representation. The Board has expanded the issue of service connection for PTSD to include all psychiatric disorders pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). The issues of service connection for an acquired psychiatric disorder other than PTSD, a kidney disability, varicose veins of the left leg, COPD and a lung disability, and for a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. In correspondence dated October 2012, prior to promulgation of a decision, the Veteran indicated that he elected to withdraw the issue of service connection for jungle rot of the bilateral feet. 2. In a July 1991 rating decision, service connection for tinea cruris of the groin was denied. 3. The evidence received more than one year since the July 1991 rating decision relates to an unestablished fact necessary to substantiate the claim of service connection for tinea cruris of the groin. 4. Current tinea cruris of the groin was first diagnosed during active service. 5. The evidence is at least evenly balanced as to whether the Veteran has PTSD that is related to an in-service stressor. 6. A preponderance of the evidence is against a finding that a low back disability had its onset in service or is otherwise related to service. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal by the Veteran as to the issue of service connection for jungle rot of the bilateral feet have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. § 20.204 (2016). 2. The RO's July 1991 denial of service connection for tinea cruris of the groin is final. 38 U.S.C.A. § 7104(a) (West 2014); 38 C.F.R. §§ 3.156(b), 20.1103 (2016). 3. New and material evidence has been received to reopen the previously denied claim for entitlement to service connection for tinea cruris of the groin. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156(a) (2016). 4. The criteria for service connection for tinea cruris of the groin are met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.301, 3.303 (2016). 5. The criteria for service connection for PTSD are met. 38 U.S.C.A. §§ 105, 1110, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.301, 3.303, 3.304 (2016). 5. The criteria for service connection for a low back disability are not met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits pursuant to 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. VA's duty to notify has been satisfied through a notice letter dated March 2012 to the Veteran, which fully addressed all notice elements related to service connection for a low back disability. Specifically, this letter informed the Veteran of what evidence was required to substantiate his claim for service connection, of the Veteran's and VA's respective duties for obtaining evidence, and the process by which disability ratings and effective dates are assigned. The Board, therefore, finds that all notices required by the Veteran Claims Assistance Act (VCAA) and implementing regulations were furnished to the Veteran and that no useful purpose would be served by delaying appellate review to send out additional VCAA notices. VA must also make reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate her claims, unless no reasonable possibility exists that such assistance would aid in substantiating the claims. 38 U.S.C.A. § 5103A ; 38 C.F.R. § 3.159 . Service treatment records are associated with the claims file. All post-service treatment records and reports identified by the Veteran have also been obtained. The Board notes that the Veteran was not afforded a VA examination to determine the nature and etiology of any low back disability. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see also 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). Under McLendon, in disability compensation (service connection) claims, VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service, but (4) insufficient competent medical evidence on file for VA to make a decision on the claim. In this case, however, as shown in the discussion below, there is no indication or even argument that a low back disability is related to or may be associated with service or that the Veteran experienced an in-service event or injury relating to the low back. In light of the foregoing, the Board is satisfied that all relevant facts have been adequately developed to the extent possible; no further assistance to the appellant in developing the facts pertinent to the issue on appeal is required to comply with the duty to assist. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Withdrawal of Appeals The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the appellant or by his or her authorized representative. Id. In the present case, in correspondence dated October 2012, prior to the promulgation of a decision, the Veteran indicated that he elected to withdraw the issue of service connection for jungle rot of the bilateral feet on appeal with the Board. Hence, there remain no allegations of errors of fact or law for appellate consideration with respect to that issue. Accordingly, the Board does not have jurisdiction to review the appeal of that issue, and it is dismissed. New and Material Evidence In July 1991, the RO denied service connection for tinea cruris of the groin. The Veteran did not appeal this decision and no new and material evidence was received within one year of this decision. As such, it became final. Bond v. Shinseki, 659 F.3d 1362, 1367-68 (Fed. Cir. 2011). As a general rule, a claim shall be reopened and reviewed if new and material evidence is presented or secured with respect to a claim that is final. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. Under 38 C.F.R. § 3.156(a), new evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). When determining whether a claim should be reopened, the credibility of the newly submitted evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). In order for the evidence to be sufficient to reopen a previously denied claim, the evidence must be both new and material. If the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. Smith v. West, 12 Vet. App. 312 (1999). If it is determined that new and material evidence has been submitted, the claim must be reopened. The Board may then proceed to the merits of the claim on the basis of all of the evidence of record. In determining whether new and material evidence has been received to reopen a claim, there is a low threshold for determining whether evidence raises a reasonable possibility of substantiating a claim. See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should consider whether the evidence could reasonably substantiate the claim were the claim to be reopened, including by triggering VA's duty to obtain a VA examination. Id. at 118. Moreover, the Veteran need not present evidence as to each element that was a specified basis for the last disallowance, but merely new and material evidence as to at least one of the bases of the prior disallowance. Id. at 120 (noting the assistance of 38 C.F.R. § 3.159(c)(4) would be rendered meaningless if new and material evidence required a claimant submit medical nexus evidence when he has provided new and material evidence as to another missing element). In July 1991, the RO denied service connection as there was no evidence showing a diagnosis of a skin disability of the groin. Since the July 1991 denial, new evidence has been submitted. In particular, the report of a March 2013 VA examination is of record. In that report, the Veteran stated that the Veteran has been diagnosed with tinea cruris (or jock itch) on and off for the past thirty years. The Board finds this evidence new and material. The petition to reopen is therefore granted. 38 C.F.R. § 3.156. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). To establish service connection, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). A. Tinea Cruris of the Groin The Veteran was afforded a VA examination in March 2013. There, the examiner declined to diagnose the Veteran with tinea cruris as there was no pathology to render a diagnosis. However, the Veteran stated that he has experienced a rash in his groin area on and off for the past thirty years. The fact that tinea cruris was not diagnosed at the March 2013 VA examination is not fatal to the Veteran's claim. Indeed, the United States Court of Appeals for Veterans Claims (Court) has recognized that some disabilities, like rashes, wax and wane due to their inherent nature. See Ardison v. Brown, 6 Vet. App. 405, 408 (1994). Further, the Veteran is competent to assert that he has experienced the same type of groin rash off and on since service. See, e.g., Grottveit v. Brown, 5 Vet. App. 91 -93 (1995). He is also competent to relay that he has been diagnosed with tinea cruris, as he did at the March 2013 VA examination. Moreover, the presence of a disability at the time of filing of a claim or during its pendency warrants a finding that the current disability requirement has been met, even if the disability resolves prior to the Board's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In service, treatment records reveal that the Veteran was diagnosed with tinea cruris. See May 1966 Chronological Record of Medical Care. The evidence indicates that tinea cruris of the groin had its onset in service and has persisted, on and off, since service. The Board finds that the Veteran's reports of tinea cruris episodically since service are credible and not contradicted by any evidence of record. Thus, the evidence is in at least equipoise as to whether the Veteran has had tinea cruris of the groin since filing his application to reopen and whether this disability is related to service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, the Board finds that he has tinea cruris of the groin that is related to service. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Entitlement to service connection for tinea cruris of the groin is therefore warranted. B. PTSD Service connection for PTSD specifically requires medical evidence diagnosing this disorder based on examination findings and in accordance with the DSM-V (where, as here, certification was after August 4, 2014); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. §§ 3.304(f), 4.125(a). If a stressor claimed by a veteran is related to the veteran's fear of hostile military activity, and a VA psychologist confirms that the claimed stressor is adequate to support a diagnosis of PTSD, a veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor, as long as the claimed stressor is consistent with the places, types, and circumstances of the veteran's service and there is no clear and convincing evidence to the contrary. 38 C.F.R. § 3.304 (f)(3). "Fear of hostile military activity" is defined to mean that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Id. An example of such an event or circumstance is incoming rocket fire. Among other stressors, the Veteran reported experiencing incoming mortar and rocket fire. See October 2009 Statement in Support of Claim for Service Connection for PTSD. The Veteran's Form DD-214 notes that the Veteran's military occupational specialty (MOS) was lineman. The Form DD-214 also confirms the Veteran's service in the Republic of Vietnam. The Veteran was afforded a VA examination in March 2013. The examiner declined to diagnose the Veteran with PTSD under the DSM-IV. The examiner stated that all the diagnostic criteria for PTSD were not met, particularly Criterion F. However, the Veteran's exposure to incoming fire was adequate to meet Criterion A (i.e., it was adequate to support a diagnosis of PTSD) and the stressor was related to the Veteran's fear of hostile military or terrorist activity. The examiner's decision to not diagnose the Veteran with PTSD under the DSM-IV, however, is not negative evidence against the Veteran. Indeed, as discussed above, for cases such as this, that were certified to the Board after August 4, 2014, the DSM-V, not the DSM-IV, applies. In February 2012, Dr. A.S., M.D., conducted a psychological evaluation of the Veteran. The Veteran was diagnosed with PTSD. Dr. A.S. noted the Veteran's exposure to deceased and wounded soldiers during service. Dr. A.S. stated that it was as likely as not that PTSD was related to service but offered no rationale for that opinion. While Dr. A.S. did not offer an explicit rationale for his conclusion, it is readily apparent that PTSD was diagnosed as a result of the Veteran's exposure to traumatic events in service. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner "did not explicitly lay out the examiner's journey from the facts to a conclusion," did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). The Veteran submitted a Disability Benefits Questionnaire (DBQ) dated July 2016. Dr. S.F., Psy.D., diagnosed the Veteran with PTSD and explained that all criteria for a diagnosis of PTSD were met. Stressors noted include exposure to incoming mortars, rockets, sniper fire, mines and booby traps. Dr. S.F. also included a comprehensive psychological evaluation along with the DBQ. Dr. S.F. concluded that it is just as likely as not that PTSD was directly due to combat service as an artilleryman who witnessed significant combat casualties and losses. He explained the Veteran was in Vietnam and experienced many life-threatening situations. That rationale, coupled with a full reading of Dr. S.F.'s report, is probative as to whether PTSD is related to service. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir.1996) (Board charged with assessing the probative value of all evidence of record). The evidence is in at least equipoise as to whether the Veteran's PTSD is related to a fear of hostile military activity. The March 2013 VA examiner confirmed that the Veteran's exposure to mortar and rocket fire in Vietnam is adequate to support a diagnosis of PTSD. Both Drs. A.S. and S.F. diagnosed the Veteran with PTSD based, in part, on the Veteran's exposure to such in Vietnam. That stressor is consistent with service in Vietnam. Further, Dr. S.F. offered a clear opinion that PTSD is related to service and offered a rationale to support that opinion. Given the above, the evidence is in at least equipoise as to whether the Veteran has PTSD that is related to a fear of hostile military activity. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for PTSD is warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. C. Low Back Disability The Veteran asserts that service connection for a low back disability is warranted. Service treatment records are absent of any evidence of any low back problems while in service. A February 1967 Report of Medical Examination notes no abnormalities of the spine. Similarly, a February 1967 Report of Medical History shows that the Veteran denied ever having recurrent back pain or any other back problems. Indeed, the first evidence of any low back problems is several decades following service. To that end, a May 1991 VA examination report (conducted, in part, based on a claim for pension) notes that the Veteran lifted a heavy object in 1988 following service and noticed a popping noise in his low back followed by severe pain. Further, private treatment records note that the Veteran complained of low back pain following a motor vehicle accident in August 1996. There is no evidence that a low back disability is related to service. Indeed, the Veteran has not presented any argument relating his back disability to service. Likewise, there is no evidence that the Veteran developed any low back problems during service or that the Veteran complained of any low back problems at that time. Rather, the evidence indicates that the Veteran began experiencing low back problems many years following service while lifting heavy items and being involved in a motor vehicle accident many years following service. The evidence reflects that a low back disability or symptoms were not present until many years following service, in relation to a motor vehicle accident or lifting items. This is one factor, in addition to those above, that leads the Board to conclude that the evidence does not reflect that the Veteran has a low back disability that may be associated with service. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (stating that evidence of a prolonged period without medical complaint is one factor that may be considered in analyzing a service connection claim). Moreover, the Veteran has made no argument and offered no evidence supporting his conclusory generalized statements that service connection for a low back disability is warranted. The low standard for affording the Veteran with a VA examination on this question has therefore not been met. Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (a conclusory generalized lay statement alleging nexus between a current disability and service does not meet the standard to warrant a VA examination). As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and entitlement to service connection for low back disability is not warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER The appeal as to the issue of service connection for jungle rot of the bilateral feet is dismissed. The application to reopen the claim for service connection for tinea cruris of the groin is granted. Service connection for tinea cruris of the groin is granted. Service connection for PTSD is granted. Service connection for a low back disability is denied. REMAND With regard to the claim for service connection for a psychiatric disorder other than PTSD, the Board notes that the Veteran was diagnosed with depressive disorder not otherwise specified (NOS) by the March 2013 VA examiner. The examiner offered no opinion as to the etiology of depressive disorder NOS. The fact that the examiner offered no etiological opinion renders the examination inadequate. The Board recognizes that service connection for PTSD was granted above. However, it is possible to separately grant service connection for both PTSD and another psychiatric disorder. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009) ("We recognize that bipolar disorder and PTSD could have different symptoms and it could therefore be improper in some circumstances for VA to treat these separately diagnosed conditions as producing only the same disability"). Given such, remand is necessary to obtain an addendum opinion as to the etiology of depressive disorder NOS. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (once VA provides an examination to a Veteran, VA has a duty to ensure that the examination is adequate for evaluation purposes). With regard to the claim for service connection for a kidney disability, the Veteran has claimed that his kidney problems were due to his exposure to herbicides. See November 2010 Report of General Information. The Veteran also reported that he was told that his problems were likely due to exposure to herbicides. See September 2010 Statement of Veteran. Lay evidence is competent when a lay person is reporting a contemporaneous medical diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). This statement therefore sufficient to trigger VA's duty to provide the Veteran an examination under McLendon. With regard to the claim for service connection for left leg varicose veins, a VA examination is necessary. Varicose veins were diagnosed at a March 1991 VA examination, in conjunction with a claim for a pension at that time. The Veteran stated that he began noticing varicose veins about 20 years prior, placing the onset of varicose veins close to the Veteran's period of service. This evidence is sufficient to trigger VA's duty to provide the Veteran an examination. McLendon, 20 Vet. App. at 81. With regard to the claims for service connection for a lung disability and COPD, the Veteran was afforded a VA examination in March 2013, where he was diagnosed with interstitial lung disease. The examiner opined that it was less likely than not that a lung disability was related to service as there were no military, VA or civilian treatment records documenting any pulmonary conditions during service. Additionally, with regard to COPD, an addendum opinion was provided in April 2013. The examiner concluded that it was less likely than not that the Veteran's COPD was related to service. As rationale, the examiner stated that the Veteran's STRs do not show any treatment for COPD, but did show treatment for an acute upper respiratory condition, which is not a long-term diagnosis. The examiner stated that the Veteran did not develop COPD and lung problems until after service. The Board finds the March 2013 opinion and April 2013 addendum opinion inadequate. The March 2013 opinion relied solely on an absence of medical records relating a lung disability to service. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). The April 2013 addendum did not address the possibility that the Veteran's conceded exposure to herbicides may have caused his COPD. The Board acknowledges the December 2010 VA treatment record noting that is possible that the Veteran's lung condition may be related to herbicide exposure. This statement is, however, in terms too ambiguous to warrant the grant of service connection. Winsett v. West, 11 Vet. App. 420, 424 (1998) (terminology equivalent to "may or may not" is an insufficient basis for an award of service connection). For those reasons, an addendum opinion regarding COPD and any lung disability is required. See Barr, 21 Vet. App. at 311-12. Finally, the TDIU issue is inextricably intertwined with the AOJ's initial assignment of a disability rating for PTSD and tinea cruris of the groin, as well as the service connection claims which are being remanded. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 2 Vet. App. 180, 183 (1991). Accordingly, the claims remaining on appeal are REMANDED for the following action: 1. Refer the Veteran's claim file to the VA examiner who conducted the March 2013 VA examination for an addendum medical opinion, if available. If the examiner is unavailable, the opinion should be requested from another appropriately qualified mental health professional. The Veteran's VA claims folder should be made available to the examiner for review in conjunction with the examination. The examiner should address the following: Whether it is at least as likely as not (at least a 50 percent probability) that depressive disorder NOS is etiologically related to service. The examiner must provide a complete rationale for any opinion set forth. In addressing this matter the examiner should address the pertinent evidence in the service treatment records, post service medical records and examinations, as well as the lay evidence provided by the Veteran. 2. Schedule a VA examination to assess the etiology of any kidney disorder. The Veteran's VA claims folder should be made available to the examiner for review in conjunction with the examination. The examiner should address the following: Whether it is at least as likely as not (at least a 50 percent probability) that any kidney disability is etiologically related to service, to include the Veteran's conceded exposure to herbicides in Vietnam. The examiner must provide a complete rationale for any opinion set forth. In addressing this matter the examiner should address the pertinent evidence in the service treatment records, post service medical records and examinations, as well as the lay evidence provided by the Veteran. 3. Schedule a VA examination to assess the etiology of any varicose veins of the left leg. The Veteran's VA claims folder should be made available to the examiner for review in conjunction with the examination. The examiner should address the following: Whether it is at least as likely as not (at least a 50 percent probability) that varicose veins of the left leg is etiologically related to service, or had its onset during service. The examiner must provide a complete rationale for any opinion set forth. In addressing this matter the examiner should address the pertinent evidence in the service treatment records, post service medical records and examinations, as well as the lay evidence provided by the Veteran. 4. Refer the Veteran's claim file to the VA examiner who April 2013 addendum medical opinion for an additional addendum medical opinion, if available. If the examiner is unavailable, the opinion should be requested from another appropriately qualified mental health professional. The Veteran's VA claims folder should be made available to the examiner for review in conjunction with the examination. The examiner should address the following: a.) Whether it is at least as likely as not (at least a 50 percent probability) that COPD is etiologically related to service, including the Veteran's conceded exposure to herbicides in Vietnam. b.) Whether it is at least as likely as not (at least a 50 percent probability) that any lung disability other than COPD (including interstitial lung disease) is etiologically related to service, including the Veteran's conceded exposure to herbicides in Vietnam. In answering the above questions, the examiner must specifically comment on the in-service diagnosis of an acute upper respiratory infection in April 1964. The examiner must provide a complete rationale for any opinion set forth. In addressing this matter the examiner should address the pertinent evidence in the service treatment records, post service medical records and examinations, as well as the lay evidence provided by the Veteran. 5. After undertaking any other development deemed appropriate, readjudicate the issues remaining on appeal. If the benefit sought is not granted, the Veteran and his attorney should be furnished with a supplemental statement of the case and afforded an opportunity to respond before the record is returned to the Board for further review. 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). ______________________________________________ Jonathan Hager Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs