Citation Nr: 1800364 Decision Date: 01/04/18 Archive Date: 01/19/18 DOCKET NO. 17-07 720 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of service connection for a kidney disorder. 2. Entitlement to service connection for a kidney disorder 3. Entitlement to service connection for a brain injury. 4. Entitlement to service connection for diabetes mellitus, to include as due to herbicide exposure. 5. Entitlement to service connection for heart disease, to include as due to herbicide exposure. 6. Entitlement to service connection for migraines. 7. Entitlement to service connection for diverticulitis. 8. Entitlement to service connection for vertigo/dizziness. 9. Entitlement to service connection for glaucoma. 10. Entitlement to service connection for a liver disorder. 11. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD). 12. Entitlement to service connection for dementia. 13. Entitlement to service connection for hypertension, to include as due to herbicide exposure. 14. Entitlement to a rating in excess of 60 percent for prostate cancer with urinary incontinence. 15. Entitlement to a compensable rating for erectile dysfunction. REPRESENTATION Veteran represented by: J. Michael Woods, Attorney ATTORNEY FOR THE BOARD S. Mishalanie, Counsel INTRODUCTION The Veteran served on active duty from February 1964 to February 1967 in the United States Marine Corps. This matter comes before the Board of Veterans' Appeals (Board) on appeal from September 2015 and September 2016 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In his November 2015 Notice of Disagreement (NOD), the Veteran indicated that he disagreed with the effective dates assigned in the September 2015 rating decision that continued the disability ratings for his service-connected prostate cancer and erectile dysfunction. The Board notes, however, that no effective dates were assigned with respect to these claims. Therefore, these issues are being referred to the Agency of Original Jurisdiction (AOJ) for appropriate action, which may include seeking clarification from the Veteran regarding his intent. See 38 C.F.R. § 19.9(b) (2017). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The issues of service connection for a kidney disorder, dementia, and hypertension are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. In a February 2009 rating decision, the RO denied the Veteran's claim of service connection for a kidney disorder. The Veteran was notified of the decision and did not appeal or submit new and material evidence within the one-year period thereafter. 2. The evidence associated with the claims file since the February 2009 rating decision relates to unestablished facts necessary to substantiate the claim for service connection for a kidney disorder and raises a reasonable possibility of substantiating the claim. 3. The Veteran does not have a brain injury, diabetes mellitus, or a heart disorder. 4. The Veteran's migraines, diverticulitis, vertigo/dizziness, glaucoma, and liver disorder did not manifest during active service and there is no indication that any of these claimed disorders are causally related to his active service. 5. The Veteran does not have PTSD related to an in-service stressor. 6. The Veteran's prostate cancer with incontinence requires him to wear absorbent material and change it more than four times per day. 7. The Veteran's erectile dysfunction is manifested by loss of erectile power for which he receives special monthly compensation (SMC); however, there is no associated penile deformity. CONCLUSIONS OF LAW 1. The February 2009 rating decision that denied a claim of service connection for a kidney disorder is final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. § 20.1103 (2017). 2. The criteria for reopening a previously denied claim of service connection for a kidney disorder have been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 3. The criteria for service connection for a brain injury have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 4. The criteria for service connection for diabetes mellitus have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 5. The criteria for service connection for heart disease have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 6. The criteria for service connection for migraines have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 7. The criteria for service connection for diverticulitis have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 8. The criteria for service connection for vertigo/dizziness have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 9. The criteria for service connection for glaucoma have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 10. The criteria for service connection for a liver disorder have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 11. The criteria for service connection for a psychiatric disorder, to include PTSD, have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304(f) (2017). 12. The criteria for the assignment of a rating in excess of 60 percent for prostate cancer with incontinence have not been met. 38 U.S.C. §§ 1155, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.115a, 4.115b, Diagnostic Code 7528 (2017). 13. The criteria for an initial compensable rating for erectile dysfunction are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 3.102, 3.159, 3.321, 4.1-4.14, 4.115b, Diagnostic Code 7599-7522 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has considered the Veteran's claims and decided entitlement based on the evidence or record. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claims. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). I. Claim to Reopen - Kidney Disorder The Board finds that new and material evidence has been received to reopen a claim of service connection for a kidney disorder. The claim was previously denied because the evidence did not show a nexus between the Veteran's kidney disorder and his military service. See February 2009 rating decision. In a July 2017 letter, Dr. H.S. opined that the Veteran's renal cell carcinoma was at least as likely as not related to his military service, to include exposure to herbicides and contaminated drinking water at Camp Lejeune. The Board finds this evidence new and material. Therefore, the claim is reopened and will be decided on the merits after additional development is undertaken, as described in the Remand section below. II. Service Connection Claims Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2017). To establish a right to compensation for a present disability, 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 - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. The law also establishes a presumption of entitlement to service connection for diseases associated with exposure to certain herbicide agents and also provides a presumption of exposure for veterans who served in the Republic of Vietnam. See 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309(e). In such circumstances, service connection may be granted on a presumptive basis for the diseases listed in 38 C.F.R. § 3.309(e), to include diabetes mellitus and ischemic heart disease, if manifested to a compensable degree at any time after active service. 38 U.S.C. § 1116(a)(1); 38 C.F.R. § 3.307(a)(6)(ii). VA shall consider all information and lay and medical evidence of record. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). A. Brain Injury, Diabetes Mellitus, and Heart Disease The Veteran asserts that he has a brain injury, diabetes mellitus, and heart disease that were incurred in or are related to his military service. Whether service connection is claimed on direct, presumptive, or secondary basis, a necessary element for establishing such a claim is the existence of a current disability. See Degmetich v. Brown, 104 F.3d 1328 (1997); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Here, there is no medical evidence establishing that he has any of these claimed disabilities. Although he has dementia, which will be addressed below, there is no evidence of any brain injury. Furthermore, a September 2015 VA examiner specifically opined that the Veteran did not have diabetes mellitus or a heart disorder. Therefore, the Board finds that service connection is not warranted for these claimed conditions. B. Migraines, Diverticulitis, Vertigo/Dizziness, Glaucoma, Liver Disorder The Veteran also asserts that his migraines, diverticulitis, vertigo/dizziness, glaucoma, and liver disorder are related to his military service. His service treatment records are unremarkable for any complaints, treatment, or diagnoses related to these conditions. At his February 1967 separation examination, his head, eyes, neurologic system, abdomen and viscera, and anus and rectum, were noted as normal. After service, VA and private treatment records indicate that the Veteran has been treated for migraines, diverticulitis, vertigo/dizziness, glaucoma, and a liver disorder. However, the Board finds the most probative evidence weighs against the claims. The first complaints and objective evidence of the claimed disabilities occurred many years after service. The passage of time between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Furthermore, there is no competent and credible evidence of record, lay or medical, linking the Veteran's claimed disorders to his military service. C. Psychiatric Disorder - PTSD The Veteran has also asserted that he has a psychiatric disorder, to include PTSD, related to his military service. Service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a), (2) credible supporting evidence that the claimed in-service stressors actually occurred, and (3) a link, established by medical evidence, between the current symptomatology and the claimed in-service stressors. See 38 C.F.R. §3.304(f). If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 U.S.C. § 1154(b) (2012); 38 C.F.R. § 3.304(f)(2) (2017). If a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means 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, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. See 38 C.F.R. § 3.304(f)(3) (2017). A September 2008 VA treatment record indicates that a PTSD screening test was negative. The Veteran denied having ever had any experience that was so frightening, horrible or upsetting that he had nightmares about it or intrusive thought; that he tried to avoid thinking about it; that he felt constantly on guard, watchful, or easily startled; and that he felt numb or detached from others, activities, and surroundings. In October 2013, a PTSD screening test was also negative. He denied having nightmares, avoidance tendencies, easy startle response, and feelings of detachment. In June 2016, the Veteran filed a claim for PTSD "due to military service exposures and compounded stress due to prostate residuals." In support of his claim, his representative attached a letter from Dr. J.W. dated in May 2016. In that letter, Dr. J.W., a private psychologist, opined that the Veteran had a diagnosis of PTSD triggered by the traumas he experienced in Vietnam. He noted that the Veteran served in combat and was involved in combat, firefights, and patrols; that he was attacked by rockets and mortars in the field; that he witnessed friends killed and wounded; and that he saw a lot of dead bodies. It was also noted that the Veteran suffered from depression, anxiety, and panic attacks; that he was suspicious and guarded; that he obsessed about safety and compulsively checked doors; that he had sleep impairment with nightmares; and that his symptoms were long-standing. In June 2016, the RO spoke with the Veteran's spouse (with his consent) who informed the RO that the Veteran was unable to travel and requested that the scheduled VA examination be conducted at the Charlotte VA Community Based Outpatient Clinic (CBOC). A VA examination was scheduled; however, the Veteran's spouse cancelled the examination, stating that he was "too far gone" to attend to the appointment. In a March 2017 letter, the Veteran's spouse stated that she spoke to the Veteran's family who indicated that the Veteran had changed after he returned from his military service, that he no long had high self-esteem, that he became a loner, that he was always paranoid, that he easily startled, and that he experienced depression. In this case, the evidence indicates that a private psychologist has diagnosed the Veteran with PTSD based on generally-described stressors related to his military service. Although these stressors are related to hostile military activity, the Board notes that the Veteran has provided no specific details regarding the stressors (e.g., names, places, or dates) and that he previously denied experiencing any frightening or upsetting events that caused him current distress. Thus, this report contradicts what the Veteran previously reported to VA personnel on two separate occasions. Given this discrepancy, the Board finds that Dr. J.W.'s diagnosis of PTSD lacks probative weight. In addition, there is no other medical evidence establishing that the Veteran meets the criteria for a psychiatric disorder related to his military service or a service-connected disorder. As noted, the Veteran was unable to attend an August 2016 VA examination because of his advanced mental and physical decline. Therefore, the Board finds that a remand to afford him another opportunity for a VA examination is not warranted. D. Conclusion The Board has considered the evidence of record, lay and medical. With regard to the lay evidence of record, the Veteran and his spouse are competent to describe what they have personally observed or experienced; however, the ultimate questions of diagnoses and etiology in this case extend beyond an immediately observable cause-and-effect relationship and are beyond the competence of lay witnesses. The Board is grateful for the Veteran's honorable service; however, given the record before it, the Board finds that evidence with regard to these claims does not reach the level of equipoise. See 38 U.S.C. § 5107 (a) ("[A] claimant has the responsibility to present and support a claim for benefits . . . ."); Fagan v. Shinseki, 573 F.3d 1282, 1286 (Fed. Cir. 2009) (stating that the claimant has the burden to "present and support a claim for benefits" and noting that the benefit of the doubt standard in section 5107(b) is not applicable based on pure speculation or remote possibility); Skoczen v. Shinseki, 564 F.3d 1319, 1323-29 (Fed. Cir. 2009) (interpreting section 5107(a) to obligate a claimant to provide an evidentiary basis for his or her benefits claim, consistent with VA's duty to assist, and recognizing that "[w]hether submitted by the claimant or VA . . . the evidence must rise to the requisite level set forth in section 5107(b)," requiring an approximate balance of positive and negative evidence regarding any issue material to the determination). Accordingly, the claims of service connection for a brain injury, diabetes mellitus, heart disease, migraines, diverticulitis, vertigo/dizziness, glaucoma, a liver disorder, and a psychiatric disorder must be denied. III. Increased Rating Claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where VA's adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or "staged" ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). A. Residuals of Prostate Cancer The Veteran's service-connected prostate cancer with incontinence has been evaluated as 60 percent disabling under Diagnostic Code 7528. 38 C.F.R. § 4.115b, Diagnostic Code 7528. Under Diagnostic Code 7528, malignant neoplasms of the genitourinary system are to be evaluated as 100 percent disabling. A note under the Diagnostic Code explains that following the cessation of surgical, X-ray, antineo- plastic chemotherapy or other therapeutic procedure, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months. Id. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of § 3.105(e) of this chapter. Id. If there has been no local reoccurrence or metastasis, rate on the residuals as voiding dysfunction or renal dysfunction, whichever is predominant. Id. In this case, the Veteran's residuals have predominately involved a voiding dysfunction. Under 38 C.F.R. § 4.115a, a 60 percent rating is assigned for voiding dysfunction that requires the use of an appliance or wearing of absorbent materials which must be changed more than 4 times per day. A 60 percent rating is the highest schedular rating available for voiding dysfunction. The Veteran was diagnosed with prostate cancer and underwent a retropubic prostatectomy in 2004. He has not had any recurrence. A February 2015 private medical record indicates that the Veteran reported experiencing urinary leakage and stated that he wore adult diapers. It was noted that nighttime urinary frequency was almost zero most of the time and occasionally once during the night. In June 2015, the Veteran filed a claim for an increased rating for his prostate cancer with incontinence. A VA examination was conducted in June 2015. The Veteran reported that he wore absorbent material that had to be changed more than 4 times per day, which meets the criteria for a 60 percent rating. See 38 C.F.R. § 4.115a. He also indicated that he had urinary frequency occurring every one to two hours and nighttime awakening to void two times during the night. VA treatment records note ongoing problems with urinary incontinence. In this case, the Veteran is receiving the maximum, 60 percent schedular rating for voiding dysfunction. The evidence does not show nor has the Veteran argued entitlement to an extraschedular rating. The Board also notes that there has been no evidence of renal dysfunction resulting from the Veteran's prostate cancer. For these reasons, the Board finds that a rating in excess of 60 percent is not warranted. B. Erectile Dysfunction The Veteran's service-connected erectile dysfunction is currently evaluated as noncompensable under Diagnostic Code 7599-7522. Pursuant to 38 C.F.R. § 4.27, hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after the hyphen. Unlisted disabilities requiring rating by analogy will be coded first with the numbers of the most closely related body part and "99." Under Diagnostic Code 7522, a 20 percent rating is warranted for deformity of the penis with loss of erectile power. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an increased evaluation for his service-connected erectile dysfunction. 38 C.F.R. § 4.7. The lay and medical evidence of evidence of record indicates that the Veteran has loss of erectile power, but does not indicate that he has a penile deformity. Therefore, the criteria for a 20 percent rating are not more nearly approximated. Moreover, the Board observes that the Veteran is in receipt of SMC pursuant to 38 U.S.C. § 1114(k) based on the loss of use of a creative organ. For these reasons, the Board finds that a compensable rating for erectile dysfunction is not warranted. ORDER New and material evidence having been submitted, the claim of service connection for a kidney disorder is reopened. Service connection for a brain injury is denied. Service connection for diabetes mellitus is denied. Service connection for a heart disorder is denied. Service connection for migraines is denied. Service connection for diverticulitis is denied. Service connection for vertigo/dizziness is denied. Service connection for glaucoma is denied. Service connection for a liver disorder is denied. Service connection for a psychiatric disorder, to include PTSD, is denied. A rating in excess of 60 percent for prostate cancer with incontinence is denied. A compensable rating for erectile dysfunction is denied. REMAND I. Kidney Disorder A September 2008 private treatment record indicates that a CT scan incidentally showed evidence of a left renal mass. It was noted that an April 2004 CT scan also showed a solid left renal mass and that a comparison on the two films showed very little interval growth and no evidence of metastatic disease. Because of the size and position of the tumor, a left radical nephrectomy was conducted. A November 2008 VA examiner noted that the Veteran did not have renal cancer and that the tumor was non-malignant. As noted above, in a July 2017 letter, Dr. H.S. opined that the Veteran's renal cell carcinoma was at least as likely as not related to his military service, to include exposure to herbicides and contaminated drinking water at Camp Lejeune; however, the evidence does not indicate clearly indicate that the Veteran had carcinoma. Given this conflicting evidence, the Board finds that VA medical opinion is needed. II. Dementia In a July 2017 letter, Dr. H.S. noted that medical research showed that individuals with chronic stress and/or PTSD have a greater statistical risk for various forms of dementia. He also indicated that there was medical research that showed a correlation between common prostate cancer treatment practices and the development of dementia later in life and that he was unclear whether the Veteran received this same therapy but that the connection should be considered. In addition, Dr. H.S. noted that the exposure to dioxins used in Agent Orange and benzene have been linked to the development of cognitive decline such as Alzheimer's. Based on the foregoing, he opined that it was at least as likely as not that the Veteran's dementia was related to his military service. As noted above, the Board has determined that the Veteran does not have a psychiatric disorder related to his military service. Therefore, at least one of the premises underlying Dr. H.S.'s opinion is invalid and the Board finds that a remand is necessary to obtain a VA medical opinion regarding the nature and etiology of the Veteran's dementia. III. Hypertension The Veteran asserts that his hypertension is related to his military service. The Board notes that the Veteran served in the Republic of Vietnam during the Vietnam era and that is assumed that he was exposed to herbicide agents. Although hypertension is not on the list of diseases that VA has associated with Agent Orange exposure, the regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. §§ 3.303(d), 3.309(e); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In other words, a presumption of service connection provided by law is not the sole method for showing causation in establishing a claim for service connection for disability due to herbicide exposure. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange). In that regard, the National Academy of Sciences' (NAS) Institute of Medicine's Veterans and Agent Orange: Update 2010 (2010 Update) concluded that there is limited or suggestive evidence of an association between exposure to Agent Orange and hypertension. Thus, a VA medical opinion is needed to address this issue. Accordingly, the case is REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his kidney disorder, dementia, and hypertension. After acquiring this information and obtaining any necessary authorizations, the AOJ should obtain and associate these records with the claims file. The AOJ should obtain any outstanding VA treatment records. 2. After obtaining any identified and outstanding records, refer the claims file to a VA examiner for an opinion regarding the nature and etiology of the Veteran's kidney disorder. The entire claims file must be made available to and be reviewed by the examiner, and it must be confirmed that such records were available for review. A thorough explanation for any opinion must be provided, including the medical bases and principles underlying his/her opinion. The examiner should indicate specifically whether the Veteran has/had kidney cancer. If not, the examiner should identify the kidney disorder and state whether it is at least as likely as not (a 50 percent probability or greater) related to his military service, including exposure to Agent Orange and/or contaminants in the water supply at Camp Lejeune (notwithstanding the fact that there may not be a presumed association). The examiner should also address Dr. H.S.'s July 2017 medical opinion. 3. After obtaining any identified and outstanding records, refer the claims file to a VA examiner for an opinion regarding the nature and etiology of the Veteran's dementia. The entire claims file must be made available to and be reviewed by the examiner, and it must be confirmed that such records were available for review. A thorough explanation for any opinion must be provided, including the medical bases and principles underlying his/her opinion. The examiner should indicate whether the Veteran's dementia is at least as likely as not (a 50 percent probability or greater) related to his military service, to include exposure to Agent Orange and/or contaminants in the water supply at Camp Lejeune (notwithstanding the fact that there may not be a presumed association). The examiner should also indicate whether the Veteran's dementia is at least as likely as not (50 percent probability or greater) caused or aggravated by (that is, permanently worsened beyond the natural progression of the disease) his service-connected prostate disability. In rendering these opinions, the examiner should address the July 2017 letter by Dr. H.S. and the medical literature cited and submitted by him. 4. After obtaining any identified and outstanding records, refer the claims file to a VA examiner for an opinion regarding the nature and etiology of the Veteran's hypertension. The entire claims file must be made available to and be reviewed by the examiner, and it must be confirmed that such records were available for review. If an examination is necessary, one must be provided. A thorough explanation for any opinion must be provided, including the medical bases and principles underlying his/her opinion. The examiner should state whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's hypertension is related to his military service, including herbicide exposure therein (notwithstanding the fact that it may not be a presumed association). The examiner must address the NAS Institute of Medicine's Veterans and Agent Orange: Update 2010 (2010 Update), which concluded that there was limited or suggestive evidence of an association between exposure to Agent Orange and hypertension. 5. After completing the above actions, the AOJ should conduct any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs. 6. When the development requested has been completed, the case should be reviewed by the AOJ on the basis of additional evidence associated with the file since the Statement of the Case. If any benefit sought is not granted, the Veteran should be furnished a Supplemental Statement of the Case and be afforded a reasonable 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 remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ ANTHONY C. SCIRÉ, JR. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs