Citation Nr: 1759916 Decision Date: 12/22/17 Archive Date: 01/02/18 DOCKET NO. 12-28 807 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for hepatitis C. 2. Entitlement to service connection for an acquired psychiatric disorder, to include as secondary to hepatitis C. 3. Entitlement to service connection for arthritis, to include of the back, legs, and hands. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Owen, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1977 to November 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied service connection for hepatitis C, a psychiatric disorder secondary to hepatitis C, and rheumatoid arthritis of the back, legs, and hands. In November 2015, the Veteran testified at a Travel Board hearing before the undersigned Veteran's Law Judge at the RO in St. Petersburg, Florida. A transcript of the hearing is associated with the claims file. In January 2016, the Board remanded the case for further development of the record, including obtaining VA examinations and medical opinions. There has been substantial compliance with the requested development. Stegall v. West, 11 Vet. App. 268 (1998); see Dyment v. West, 13 Vet. App. 141 (1999). This appeal was processed using the Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing system. Accordingly, any future consideration of this case should take into consideration the existence of this electronic record. The issues of service connection for arthritis, to include of the back, legs, and hands, is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's hepatitis C did not have its onset during service, was first diagnosed years after active service, and is not otherwise etiologically related to active service, to include hepatitis incurred therein. 2. An acquired psychiatric disorder was not shown in service, and is not related to service or to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for hepatitis C have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2017). 2. The criteria for entitlement to service connection for an acquired psychiatric disorder, to include as secondary to hepatitis C, have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5103, 5013A, 5106, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was advised of VA's duties to notify and assist in the development of the claims at issue by notice letters dated in March and April 2010. See 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The VCAA also provides that VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. 38 U.S.C. § 5103A; 38 C.F.R § 3.159(c). Here, the Veteran's service records, VA records, and private treatment records identified by the Veteran have been obtained and associated with the claims file. The Veteran was afforded VA examinations in August 2010, August 2012, and October 2016. The examinations are of record. To that end, when VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examination reports reflect that relevant records were reviewed and the examiner personally interviewed and examined the Veteran, including eliciting a history from him, and offered opinions. The Veteran has been afforded a meaningful opportunity to participate effectively in the processing of the claim, including by submission of statements and arguments. Based upon the foregoing, the duties to notify and assist the Veteran have been met, and no further action is necessary to assist the Veteran in substantiating this claim. Service Connection Laws and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). 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). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The U.S. Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement to service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability, there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). In this case, arthritis is a chronic disease listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions based on "chronic" in-service symptoms and "continuous" post-service symptoms under 38 C.F.R. § 3.303(b) do apply. Fountain v. McDonald, 27 Vet. App. 258, 274-75; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of a "chronic" disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With a chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such arthritis, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. It may also include statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of a disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154(a) (2012); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis; or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the veteran. See 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017). Analysis Hepatitis C The Veteran contends that service connection is warranted for hepatitis C. Specifically, he states that he developed hepatitis C in service due to jet gun inoculations and that several others in his unit, including his roommate, developed hepatitis C. The Veteran further states that although he was treated for hepatitis B in service, he believes he was misdiagnosed as the doctors were not completely sure if he had hepatitis B or something else. See April 2010 VA Form 21-4138 (Statement in Support of Claim). The Veteran argues that he was not diagnosed with hepatitis C in service because there was no test to diagnose hepatitis C at that time. On a September 1977 entrance examination, the Veteran denied having liver trouble. The Veteran's service treatment records reflect that in April 1979, the Veteran was admitted with malaise, nausea, anorexia, low back pain, headache, and chills. The Veteran tested HAA-positive by auscell method for hepatitis. The Veteran was hospitalized for eight days and felt better upon discharge. The final diagnosis was HAA-positive hepatitis, resolving. In August 1979, the Veteran was noted to be under no current treatment for his previous hepatitis. There is no separation examination associated with the Veteran's service treatment records, but his service treatment records are otherwise silent for complaints of or treatment for hepatitis. The medical evidence of record reflects that the Veteran was diagnosed with hepatitis C in 1986 and began taking interferon in 1998. An August 2010 VA examination report reflects that the examiner noted an in-service diagnosis of HAA-positive hepatitis and a current diagnosis of inactive hepatitis C. The examiner opined that the Veteran's hepatitis C was not related to events that incurred in service, as the Veteran had acute hepatitis that was HAA-positive. In August 2010, the RO denied service connection for hepatitis C, finding that although the Veteran had been diagnosed with hepatitis A in service, there was no current evidence of this acute condition and the VA examiner was unable to relate the Veteran's in-service hepatitis with his current hepatitis C. The Veteran's medical treatment records reflect that in September 2010, the Veteran tested positive for hepatitis B and C viruses, without any evidence of active disease. The Veteran tested negative for hepatitis A. See September 2010 and October 2015 VA treatment records. In August 2012, a VA examiner provided an addendum opinion, finding that the Veteran's hepatitis C was not secondary to jet gun immunizations. The examiner noted that there was no acceptance in the medical literature that jet gun immunizations were a risk factor for hepatitis C, and that the Centers for Disease Control and the National Institutes of Health did not recognize or advocate screening for jet gun immunizations as a risk factor. The examiner further noted that a percentage of patients who contract hepatitis C have no risk factors. In December 2015, the Veteran submitted a private opinion from his treating physician. The Veteran's physician reviewed the Veteran's service treatment records and post-service treatment records and opined that the Veteran's hepatitis C was caused by or a result of service or events in service. See December 2015 letter of Dr. A. In January 2016, the Board remanded the claim for additional development, noting that the private December 2015 provided no basis or rationale and that the VA opinions did not discuss whether the Veteran's hepatitis C could have been misdiagnosed as hepatitis A in service. In October 2016, a VA examiner provided an addendum opinion. The examiner opined that the Veteran's hepatitis C was not proximately due to or the result of the Veteran's in-service hepatitis. The examiner found that the Veteran's hepatitis C was not caused by hepatitis A. Furthermore, the fact that there was no test for hepatitis C at the time the Veteran developed hepatitis A was irrelevant, as the possibility of having hepatitis C in that circumstance only applied to those who were deemed to have non-A/non-B hepatitis. The Board notes that the Veteran was diagnosed with HAA-positive hepatitis, which is the former term used for the hepatitis B virus surface antigen before its nature was established. See Dorland's Illustrated Medical Dictionary 105, 815 (32d ed. 2012). The Board also notes that although the Veteran was diagnosed with HAA-positive hepatitis in service, the RO referred to the Veteran's in-service HAA-positive hepatitis as hepatitis A in the August 2010 rating decision. September 2010 treatment records reflect that the Veteran is negative for hepatitis A virus. Although subsequent adjudication noted the Veteran as having had hepatitis A in service, the Board finds that this mistake was not prejudicial to the Veteran and has resolved any ambiguity in favor of the Veteran. After considering the evidence of record as a whole, the Board concludes that service connection for hepatitis C is not warranted, as the Veteran has not shown that this disease manifested in service or within one year of service, or is otherwise related to an in-service event. While there was a diagnosis of "acute" HAA-positive hepatitis, or hepatitis B, in service, the infection apparently resolved without chronic residual disability. When the Veteran was discharged from the hospital after diagnosis, he reported that he felt better, and his doctor noted that his hepatitis was resolving. Several months after his diagnosis, the Veteran reported that he was not taking any medication to treat hepatitis. In addition, recent treatment records reflect that the Veteran has no active hepatitis B disease. As to the Veteran's diagnosis of hepatitis C, the medical evidence of record reflects that he was diagnosed with hepatitis C in 1986, which was several years after separation from service. The Veteran contends that he contracted hepatitis C from jet gun inoculations in service and that others in his unit developed hepatitis C. However, an August 2012 VA examiner opined that the Veteran's hepatitis C was not caused by the jet gun inoculations. The Board finds this opinion adequate and probative, as the examiner's opinion was supported by adequate rationale with consideration of the medical literature. Although the Veteran provided a private opinion in support of a nexus between his hepatitis C and service, the Board has previously found, and continues to find, this opinion is inadequate as it was not supported by a basis or rationale. Therefore, the Board assigns the private opinion less probative weight. To the extent that the Veteran asserts that he was misdiagnosed with hepatitis B in service, and that he actually had hepatitis C, the Board notes that objective laboratory testing found that he had HAA-positive hepatitis. Although the Veteran argues that he could not be diagnosed with hepatitis C as there was not yet a test to diagnose hepatitis C, the October 2016 VA examiner stated that the possibility of having hepatitis C in that circumstance only applied to those who were deemed to have non-A/non-B hepatitis. As the Veteran was identified as having HAA-positive hepatitis, this circumstance becomes inapplicable. The Board acknowledges that a claimant is generally competent to introduce lay testimony of observable symptoms of disability and continuity of such symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, as a lay person, the Veteran is not competent to provide a medical diagnosis or nexus regarding his current hepatitis C and whether his hepatitis C was misdiagnosed as hepatitis B or related to in-service jet gun inoculations; such a matter requires medical expertise and laboratory testing. See id. at 1377 (noting general competence to testify as to symptoms but not to provide medical diagnosis). As such, the Board finds the Veteran's representations in this regard to be of extremely limited probative value and significantly outweighed by the objective laboratory testing which found HAA-positive hepatitis in-service and the opinions expressed concerning the relationship between the Veteran's in-service hepatitis and current hepatitis C in the above compensation examination medical opinions. The Board finds no probative evidence that the Veteran's hepatitis C first manifested during active service or is related to any incident of service. Rather, the hepatitis diagnosed during service was HAA-positive hepatitis, which ultimately resolved. As the preponderance of the evidence is against the claim of service connection for hepatitis C, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017). Acquired psychiatric disorder The Veteran contends that service connection is warranted for a psychiatric disorder secondary to hepatitis C. Specifically, the Veteran states that the medication used to treat his hepatitis C caused depression, a known side effect of the medication. As discussed above, the Board has denied service connection for hepatitis C; therefore, service connection cannot be granted for an acquired psychiatric disorder as secondary to non-service-connected hepatitis C. 38 C.F.R. § 3.310(a). The Board will proceed with consideration of the issue of direct service connection for an acquired psychiatric disorder. See 38 C.F.R. § 3.303(d). On a September 1977 entrance examination, the Veteran denied having nervous trouble, depression, or excessive worry. There is no separation examination associated with the Veteran's service treatment records, but his service treatment records are otherwise silent for complaints of or treatment for any sort of psychiatric disorder. At the Veteran's November 2015 hearing, he testified that he did not have any mental health issues until he began medication to treat his hepatitis in the late 1980's. In 1998, the Veteran participated in a study to treat his hepatitis C with interferon. Depression was noted as a side effect on the informed consent notification. In 1999, billing records reflect a diagnosis of anxiety, and treatment records since then reflect continuing treatment for depression and anxiety. See August 2001 through October 2009 private treatment records. The Veteran was afforded a VA examination in July 2010. The Veteran reported outpatient treatment for a mood disorder, diagnosed as depression, since 1986. The examiner noted that depression was a common side effect of interferon treatment and that the Veteran has been taking antidepressant medication since. Upon examination, the examiner diagnosed the Veteran with mood disorder due to general medical condition (hepatitis C sequelae). Therefore, the examiner opined that the Veteran's depressive condition was at least as likely as not caused by his hepatitis C. The examiner noted that the Veteran manifested no psychiatric symptoms or diagnoses prior to his initial treatment for hepatitis C, and his hepatitis C medication treatment resulted in a common depressive side effect for which the Veteran has continued to have daily variable depressive symptoms which have required continuous antidepressant medication since 1986. The Board finds the VA examiner's opinion is adequate, as the examiner reviewed the claims file, physically examined the Veteran, considered the relevant history of his symptoms, and included a clear rationale for his opinion. Stefl v. Nicholson, 21 Vet. App. 120, 13-24 (2007); Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (holding that once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, VA must ensure that the examination provided is adequate). The medical evidence of record fails to demonstrate that the Veteran's psychiatric disability occurred in or manifested within one year of service. For the reasons discussed above, a preponderance of the evidence is against the claim for service connection for a psychiatric disability. Because the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (2017). ORDER Entitlement to service connection for hepatitis C is denied. Entitlement to service connection for an acquired psychiatric disorder, to include as secondary to hepatitis C, is denied. REMAND The Veteran contends that service connection is warranted for arthritis, to include of his back, legs, and hands. Specifically, he states that right after discharge from active duty, he started having arthritis problems and he was diagnosed with rheumatoid arthritis. See April 2010 VA Form 21-4138 (Statement in Support of Claim). He also contends that his arthritis is secondary to his hepatitis C. On a September 1977 entrance examination, the Veteran denied swollen or painful joints; arthritis, rheumatism, or bursitis; bone, joint, or other deformity; recurrent back pain, trick or locked knee, or foot trouble. It was noted that he had a right wrist fracture prior to service. Service treatment records reflect that in November 1977, the Veteran reported with left knee pain and swelling. The Veteran was diagnosed with chondromalacia and told to use a knee brace and apply heat. In December 1977, the Veteran reported with complaints of pain over his right patella area. An associated radiographic report was negative and he was diagnosed with knee strain. In March 1978, the Veteran reported bilateral knee pain. Upon examination, the Veteran was found to have mild nerve entrapment, slight crepitus, and mild increased recurvatum. He was diagnosed with possible early chondromalacia and the goal became management of bilateral knee pain. In February 1978, the Veteran reported with bilateral foot pain and he was diagnosed with bilateral plantar fascia strain. In August 1979, the Veteran injured his thumb while working on a tank track. He was diagnosed with a laceration and nondisplaced fracture of the left distal phalanx. In June 1981, the Veteran reported with complaints of a painful and swollen left ring finger. There is no separation examination associated with the Veteran's service treatment records, but his service treatment records are otherwise silent for complaints of or treatment for arthritis or other skeletal complaints. After service, billing records kept and submitted by the Veteran indicate the Veteran had been diagnosed with rheumatoid arthritis. See October 1999 and February 2000 billing statements. In August 2010, the RO denied the Veteran's claim on the basis that the Veteran did not have a current diagnosis of rheumatoid arthritis. In November 2015, the Veteran testified at a Board hearing that although he was diagnosed with rheumatoid arthritis, his current doctor said that he did not have rheumatoid arthritis, but rather osteoarthritis. In December 2015, the Veteran submitted a nexus statement in which his doctor opined that his degenerative arthritis was caused by or a result of events in service. In a January 2016 decision, the Board found that the December 2015 private opinion did not provide a sufficient basis on which to grant service connection. The Board found that a remand was necessary in order to obtain a VA examination and medical opinion and further recharacterized the Veteran's claim as a claim of service connection for arthritis. The Veteran was afforded a VA examination in October 2016. The examiner noted that the Veteran's e-folder was reviewed, including VBMS and CPRS. As to the Veteran's back, the examiner found that the Veteran did not have nor had ever been diagnosed with a back condition. The examiner noted that the Veteran denied any back injury and was receiving not current treatment. Thus, the examiner opined that the Veteran did not have a diagnosis of arthritis of the back that was as likely as not incurred in or caused by service, as the Veteran had a negative separation examination or evidence of continuity, there was no service treatment record evidence of any degenerative joint disease, and there was not currently any disability at all. As to the Veteran's lower extremities, the Veteran reported he was diagnosed with a knee and/or lower leg condition in service and that he has had continued pain ever since. However, the examiner found there was no evidence of continuity. The examiner noted that the Veteran had avascular necrosis of the hip, but that it was not degenerative joint disease and not related to service. The examiner opined that it was less likely than not that the Veteran had a diagnosis of arthritis that was incurred in or caused by service, finding that there was neither evidence in the medical literature, or consensus in the medical community, or evidence in the Veteran's case, that supported a causal/aggravation relationship between his conditions. As to the Veteran's hands, the Veteran reported that he developed bilateral hand pain after service. The examiner noted that the Veteran had bilateral degenerative arthritis, but that it was age-related and less likely as not incurred in or caused by service, as there was no current diagnosis, negative separation examination, or evidence of continuity. The examiner stated that there was no evidence in the medical literature or consensus in the medical community, or evidence in the Veteran's case, that supported a causal/aggravation relationship between any possible degenerative joint disease and in-service injury. The Board finds the October 2016 examiner's opinion is inadequate. It is not clear that the examiner considered the records reflecting the Veteran's 1999 diagnosis of rheumatoid arthritis when determining that there was no continuity. Although the examiner stated that VBMS and CRPS had been reviewed, the examiner did not mention the Veteran's in-service injuries and complaints, or his diagnosis of chondromalacia; therefore, it is not clear that the examiner considered these when rendering an opinion. With regards to the Veteran's back, the examiner stated that the Veteran had never been diagnosed with a back condition nor was he receiving treatment for his back. However, medical evidence reflects that the Veteran was diagnosed with back strain in May 2002, a March 2005 x-ray revealed facet degenerative sclerosis at L5-S1, and an April 2017 x-ray revealed mild to moderate spondylosis. Furthermore, the medical record of evidence shows complaints of chronic back, knee, feet, and/or hand pain up through July 2017. As such, the Board finds that a remand is warranted for an addendum opinion to address the nature and etiology of the Veteran's arthritis. In addition, in April 2010, the Veteran provided the RO with the names of Drs. Brown and Raitz, who treated him for rheumatoid arthritis in June 1982 and June 1998. See April 2010 VA Form 21-4142 (Authorization and Consent to Release). In May 2010, the Veteran was notified that the RO could not request medical records from Drs. Brown and Raitz, as they did not have complete addresses, and requested that the Veteran provide addresses. See May 2010 notification letter. Although it does not appear that the Veteran did not receive the notification letter, the RO only made one attempt to obtain these records and/or information from the Veteran. VA is required to make reasonable attempts to obtain relevant records. 38 C.F.R. § 3.159 (2017). Reasonable efforts should include at least one follow-up attempt following an initial request for records. Id. The record does not indicate a follow-up attempt was made to obtain the information from the Veteran, and the record reflects that the treatment records of Drs. Brown and Raitz may be pertinent to the Veteran's claim for arthritis. Therefore, upon remand, a second attempt should be made to assist the Veteran in obtaining relevant records. Accordingly, the case is REMANDED for the following actions: 1. The Veteran should be requested to provide names and addresses of the medical care providers who treated him for rheumatoid arthritis, including Drs. Brown and Raitz. The Veteran should be provided with appropriate releases to VA to obtain any identified sources of treatment. Thereafter, the RO should attempt to obtain outstanding records from any identified sources for which the Veteran has provided appropriate signed releases and associate any obtained records with the Veteran's claims file. All attempts to obtain these records should be documented in the file. If the RO cannot obtain records identified by the Veteran, a notation to that effect should be placed in the claims file. 2. After the above development has taken place, return the Veteran's claims file to the October 2016 VA examiner for an opinion as the nature and etiology of the Veteran's arthritis. If the examiner is unavailable, the claims file must be provided to an examiner who is qualified to give an opinion on the Veteran's arthritis, so that a new opinion may be provided. A new examination is only required if deemed necessary by the examiner. The record and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. If a new examination is conducted, the examiner must take a detailed history from the Veteran. If there is any clinical or medical basis for corroborating or discounting the reliability of the history provided by the Veteran, the examiner must so state, with complete explanation of such a finding. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater possibility) that the Veteran's currently diagnosed arthritis, to include osteoarthritis of the back, legs, and hands, began during or is related to the Veteran's active service; or began within one year of service. Although a thorough review of the pertinent medical evidence is required, the Board draws the examiner's attention to the Veteran's possible diagnosis of chondromalacia in service, his diagnosis of rheumatoid arthritis in 1999, and diagnosis of osteoarthritis in 2000. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions, based on his or her clinical experience, medical expertise, and established medical principles. If an opinion cannot be made without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. The examiner is advised that the term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. More likely and as likely support the causal relationship. Less likely weighs against the claim. 3. After completing the above, and any other development as may be indicated, the Veteran's claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs