Citation Nr: 1801775 Decision Date: 01/10/18 Archive Date: 01/23/18 DOCKET NO. 16-49 307 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for colon cancer. 2. Entitlement to service connection for erectile dysfunction. 3. Entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for tinnitus. 5. Entitlement to service connection for a psychiatric disorder. 6. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD S. D. Regan, Counsel INTRODUCTION The Veteran served on active duty in the Army from April 1964 to March 1966, including in the Republic of Vietnam. This matter is before the Board of Veterans' Appeals (Board) on appeal of a June 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office in Cleveland, Ohio, that denied service connection for colon cancer, to include as due to Agent Orange exposure, and denied service connection for erectile dysfunction, to include as secondary to colon cancer. By this decision, the RO also denied service connection for bilateral hearing loss; tinnitus; and for a psychiatric disorder, to include depression (listed as depression). The RO further denied the Veteran's claim for TDIU. In a VA Form 9, received in October 2016, the Veteran requested a Board videoconference hearing. He was scheduled for the hearing in August 2017. Following an August 2017 pre-hearing teleconference, the Veteran's representative submitted a written statement requesting waiver of the hearing request, as well as waiver of the right to an Informal Hearing Presentation, if a VA opinion was obtained as to the issue of entitlement to service connection for colon cancer, to include as due to Agent Orange exposure, and that the Veteran's exposure to in-service acoustic trauma, as to the issues of entitlement to service connection for bilateral hearing loss and for tinnitus, was conceded. As such, the Veteran's hearing request is deemed withdrawn. 38 C.F.R. § 20.704(e) (2017). In September 2017, the Board requested a Veterans Health Administration (VHA) opinion, as to the issue of entitlement to service connection for colon cancer, to include as due to Agent Orange exposure, and the VHA opinion was obtained in November 2017. In December 2017, the Veteran and his representative were provided with a copy of the October 2017 VHA opinion. In December 2017, the Veteran's representative submitted additional argument in support of his appeal. The Board notes that in a VA Form 9, received in September 2016, the Veteran raised an issue of entitlement to service connection for hypertension. There is no indication that the Veteran and/or his representative have filed the proper form as to that possible claim. See 38 C.F.R. § 3.155 (a) (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.A. § 7107(a)(2) (West 2014). The issues of entitlement to service connection for erectile dysfunction and for a psychiatric disorder, to include depression, as well as the issue of entitlement to 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. The Veteran's colon cancer was not present during service or for many years thereafter, and was not caused by any incident of service, including Agent Orange exposure. 2. The Veteran's current bilateral hearing loss had its onset in service. 3. The Veteran's current tinnitus had its onset in service. CONCLUSIONS OF LAW 1. The criteria for service connection for colon cancer, to include as due to Agent Orange exposure, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 2. Bilateral hearing loss was incurred in service. 38 U.S.C.A. §§ 1110, 1154(a), 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.385 (2017). 3. Tinnitus was incurred in service. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Colon Cancer Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a). A veteran who served in the Republic of Vietnam during the Vietnam era is presumed to have been exposed during such service to certain herbicide agents (e.g., Agent Orange). In the case of such a veteran, service incurrence for the following diseases will be presumed if they are manifest to a compensable degree within specified periods, even if there is no record of such disease during service: chloracne or other acneform diseases consistent with chloracne, type 2 diabetes, Hodgkin's disease, chronic lymphocytic leukemia, multiple myeloma, non-Hodgkin's lymphoma, acute and sub-acute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, and trachea), and soft-tissue sarcomas. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307 (a)(6), 3.309(e). Effective August 31, 2010, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), is included as a disease associated with herbicide exposure under 38 C.F.R. § 3.309 (e). (Under 38 C.F.R. § 3.309 (e), the term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of Ischemic heart disease. 38 C.F.R. § 3.309 (e) (Note 3.). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson 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, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). The Veteran contends that he has colon cancer that is related to service, to include as due to Agent Orange exposure. He specifically maintains that he served in Vietnam and that he was exposed to Agent Orange. He also reports that he was exposed to unsanitary conditions in Vietnam which may have led to his colon cancer. The Veteran indicates that he was diagnosed with colon cancer in 2003. The Veteran served on active duty in the Army from April 1964 to March 1966, including service in the Republic of Vietnam. Therefore, his exposure to Agent Orange is conceded. The Veteran's service treatment records do not show treatment for colon cancer, or for any gastrointestinal and/or bowel or rectal problems. Post-service private and VA treatment records show treatment for colon cancer (colon carcinoma), status post a colectomy. Such records indicate that the Veteran has a colostomy bag and that he underwent radiation and chemotherapy for his colon cancer. A VHA opinion, received in November 2017, was provided by an expert in colorectal surgery. The VHA expert indicated that there was no record of colon cancer or any other gastrointestinal problems while the Veteran was on active duty. The expert reported that the Veteran was diagnosed with colorectal cancer in 2003. The expert stated that the Veteran subsequently underwent radiation and chemotherapy, along with surgery and the creation of a colostomy bag. The expert maintained that based on such treatment, the Veteran presumably had rectal cancer (e.g., cancer developing in the distalmost 15 cm of the large intestine). The expert referred to several medical treatises and discussed the respective findings in some detail. The expert reported that well-known risk factors for developing colorectal cancer included a family history of the same condition; advancing age; dietary factors, such has a high fat and low fiber diet; inflammatory bowel disease; and type 2 diabetes mellitus. The expert indicated that regarding the Veteran's claim that unsanitary conditions in Vietnam contributed to his colorectal cancer, there was no evidence that sanitation correlated with developing that specific malignancy. The expert maintained that it was highly unlikely that the Veteran developed colorectal cancer while serving in Vietnam (circa 1966), which remained undiagnosed until 2003. It was noted that such cancer would cause definite symptoms much sooner and a distant, metastatic spread would develop. The expert stated that, furthermore, there was no documentation of treatment for, or symptoms of, gastrointestinal problems during the Veteran's period of service. The expert indicated that based on the reviewed medical and epidemiologic evidence, there was no identified causation or link between Agent Orange exposure and colorectal cancer. The examiner commented that, therefore, it was deemed unlikely that the Veteran's colorectal cancer was related to his presumed in-service Agent Orange exposure. The Board observes that although exposure to Agent Orange is conceded due to the Veteran's service in Vietnam, his colon cancer is not among the diseases listed as presumptively associated with Agent Orange exposure. Thus, the Veteran is not entitled to service connection on a presumptive basis. 38 C.F.R. § 3.309(e). The Veteran may, nonetheless, establish service connection if the evidence shows that his current colon cancer was, in fact, caused by exposure to Agent Orange or some other incident of service. See Combee v. Brown, 34 F.3d at 1039 (Fed. Cir. 1994). The Board notes that the probative evidence of record does not suggest that the Veteran's colon cancer is related to his period of service. In fact, the probative evidence of record is against this finding, indicating that the Veteran's present colon cancer began many years after service, without relationship to service, to include any Agent Orange exposure. A VHA expert, in very probative opinions, has specifically found that the Veteran's colon cancer was not related to his period of service, to include Agent Orange exposure. The expert also specifically indicated that regarding the Veteran's claim that unsanitary conditions in Vietnam contributed to his colorectal cancer, there was no evidence that sanitation correlated with developing that specific malignancy. The Veteran has asserted that his colon cancer had its onset during his period of service. While the Veteran is competent to report that he had problems during service or since service that he thought were related to colon cancer, he is not competent to diagnose his currently claimed colon cancer as related to service, to include as due to exposure to Agent Orange. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition, or reporting a contemporaneous medical diagnosis, or the lay testimony describing symptoms at the time supports a later diagnosis by a medical professional); Buchanan v. Nicholson, 451 F.3d. 1331 (Fed. Cir. 2006) (lay evidence is one type of evidence that must be considered and competent lay evidence can be sufficient in and of itself). Similarly, the Veteran is not competent to provide a nexus, and a medical opinion from a medical professional has not related his colon cancer to his period of service. Thus, the Veteran's lay assertions are not competent or sufficient. The preponderance of the evidence is against the claim for entitlement to service connection for colon cancer, to include as due to Agent Orange exposure; there is no doubt to be resolved; and service connection for a colon cancer, to include as due to Agent Orange exposure, is not warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II. Bilateral Hearing Loss and Tinnitus Impaired hearing will be considered to be a disability for VA purposes when the thresholds for any of the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz are 40 decibels or more; the thresholds for at least three of these frequencies are 26 decibels; or speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2017). One requirement for service connection is the current existence of the claimed disability. With regard to hearing loss, 38 C.F.R. § 3.385 defines what constitutes the current existence of a hearing loss disability. For service connection, it is not required that a hearing loss disability by the standards of 38 C.F.R. § 3.385 be demonstrated during service, although a hearing loss disability by the standards of 38 C.F.R. § 3.385 must be currently present, and service connection is possible if such current hearing loss disability can be adequately linked to service. Ledford v. Derwinski, 3 Vet. App. 87 (1992). The Veteran contends that he has bilateral hearing loss and tinnitus that are related to service. He specifically maintains that he has bilateral hearing loss and tinnitus as a result of acoustic trauma while serving in the military police during his period of service. He indicates that he was exposed to excessively loud noise from the firing of M-1 rifles and .45 caliber pistols, as well as from jeeps and 2.5 ton truck engines. The Veteran essentially asserts that his bilateral hearing loss and tinnitus were first experienced during service and have continued since that time. The Veteran served on active duty in the Army from April 1964 to March 1966, including in the Republic of Vietnam. His DD Form 214 lists his occupational specialty as in the military police. The Veteran's service treatment records do not show a hearing loss disability in either ear as defined by 38 C.F.R. § 3.385. Such records also do not show complaints, findings, or diagnoses of tinnitus. There is no specific evidence of hearing loss within the year after service as required for the presumption of service connection. The evidence of record does show that the Veteran was exposed to in-service acoustic trauma and that he has been currently diagnosed with bilateral hearing loss, under the provisions of 38 C.F.R. § 3.385, and with tinnitus. The Board notes that there are negative opinions of record, as to the etiology of the Veteran's bilateral hearing loss and tinnitus, pursuant to a May 2014 VA audiological examination report. The May 2014 VA audiological examination report includes a notation that the Veteran's claims file was reviewed. The Veteran reported that his occupation in the military police during service exposed him to excessively loud noises and/or acoustic trauma from the firing of M-1 rifles and .45 caliber pistols, as well as from jeeps and 2.5 ton truck engines. The Veteran indicated that he had post-service noise exposure as a UPS truck driver for twenty-eight years, without the use of hearing protection. He also stated that he had recreational exposure from racing cars for approximately ten years without the use of hearing protection. The Veteran reported that he had recurrent tinnitus. He stated that he first noticed his intermittent, bilateral, tinnitus around 1994. It was noted that the Veteran indicated that he did not know how his tinnitus started, he just noticed it one day. The examiner reported results that were indicative of bilateral hearing loss as defined by 38 C.F.R. § 3.385. The diagnoses were sensorineural hearing loss, in the frequency range of 500 to 4000 Hertz, in the right ear; sensorineural hearing loss, in the frequency range of 500 to 4000 Hertz, in the left ear; and tinnitus. The examiner commented that it was not at least as likely as not (50 percent probability or greater) that the Veteran's right ear hearing loss and left ear hearing loss were caused by, or a result of, an event in military service. The examiner reported that the Veteran's military occupational specialty was in the military police and that he was also awarded the Sharpshooter (Rifle M-1) Badge; the Marksman (Pistol .45) Badge; the Marksman (Rifle M-14 Badge); and the Vietnam Service Medal. The examiner stated that the RO had indicated that the evidence of record showed that the Veteran's occupational specialty was in the military police and that, therefore, excess noise exposure was conceded as moderate. The examiner referred to the hearing evaluations, pursuant to the Veteran's February 1964 pre-induction examination report and his March 1966 separation examination report, respectively. The examiner reported that upon the Veteran's separation from service, he had normal hearing acuity in the right ear and the left ear. The examiner also stated that when the Veteran's separation examination from March 1966 was compared with his February 1964 pre-induction examination, there were no significant threshold shifts in the right ear or the left ear. The examiner commented that, therefore, it was less likely than not (less than 50 percent probability) that the Veteran's current hearing loss in the right ear and his current hearing loss in the left ear were due to the conceded noise exposure he was exposed to while in the service. It was noted that right ear hearing loss and left ear hearing loss did not exist prior to service. The examiner indicated that it was less likely than not (less than 50 percent probability) that the Veteran's tinnitus was caused by, or a result of, his military noise exposure. The examiner reported that although tinnitus could manifest years after a noise injury had occurred, when the Veteran's separation examination report was compared to his pre-induction examination report, there were no significant threshold shifts noted in either ear. The examiner stated that such results suggested that the Veteran did not suffer a noise injury while in the service. The examiner maintained that there was also no complaint of tinnitus in the Veteran's service treatment records. The examiner reported that, additionally, the Veteran indicated that his tinnitus did not begin until around 1994 or roughly twenty-eight years after his discharge from service. The examiner commented that, therefore, there was no strong nexus linking the Veteran's current complaint of tinnitus with his noise exposure while in the service, and, as such, it was less likely than not (less than 50 percent probability) that his current tinnitus was due to noise exposure during his military service. The Board observes that the examiner, pursuant to the May 2014 VA audiological examination, essentially indicated that the Veteran's bilateral hearing loss was not related to his period of service because there was no worsening in the audiological evaluations when comparing the pre-induction and separation examinations. The examiner specifically stated that when the Veteran's separation examination from March 1966 was compared with his February 1964 pre-induction examination, there were no significant threshold shifts in the right ear or the left ear. The examiner commented that, therefore, it was less likely than not that the Veteran's current hearing loss in the right ear and his current hearing loss in the left ear were due to the conceded noise exposure he was exposed to while in the service. The Board notes, however, that, in regard to the Veteran's bilateral hearing loss, the absence of documented hearing loss, as defined by VA, while in service is not fatal to a claim for service connection. See Ledford, 3 Vet. App. at 87. Additionally, when a Veteran does not meet the regulatory requirements for a disability at separation, he can still establish service connection by submitting evidence that a current disability is causally related to service. Hensley v. Brown, 5 Vet. App. 155, 159-160 (1993). Further, the examiner indicated that the Veteran's tinnitus was not related to military noise exposure because, in part, the Veteran's service treatment records did not suggest that the Veteran suffered a noise injury while in the service. The Board observes, however, that acoustic trauma during service is already conceded in this case. The examiner also stated that the Veteran reported that his tinnitus did not begin until around 1994. The Board notes, however, that in his July 2013 original claim, the Veteran reported that his tinnitus began in April 1965. Additionally, the VA examiner, pursuant to the May 2014 VA audiological examination report, did not address the Veteran's reports of hearing problems and tinnitus since his period of service. The Veteran is competent to report in-service hearing problems and tinnitus, continuous hearing loss and tinnitus symptomatology since service, and current symptoms that form the basis for diagnosis of disability. See Davidson, 581 F.3d at 1313. Therefore, the Board finds that the opinions provided by the VA examiner, pursuant to the May 2014 VA audiological examination, have no probative value. The Veteran is competent to report hearing problems and ringing in the ears during service and since that time. Moreover, the Board finds that the Veteran's reports of noise exposure during his period of service, and hearing problems and tinnitus since service, are credible. See also Jandreau v. Nicholson, 492 F.3d 1372 (2007). Resolving any doubt in the Veteran's favor, the Veteran has bilateral hearing loss and tinnitus that had their onset during his period of service. Service connection for bilateral hearing loss and for tinnitus is warranted. ORDER Service connection for colon cancer, to include as due to Agent Orange exposure, is denied. Service connection for bilateral hearing loss is granted. Service connection for tinnitus is granted. REMAND The remaining issues on appeal are entitlement to service connection for erectile dysfunction and for a psychiatric disorder, to include depression, as well as the issue of entitlement to a TDIU. The Veteran contends that he has erectile dysfunction and a psychiatric disorder, to include depression, that are related to service. He has also reported that he has erectile dysfunction secondary to colon cancer. As discussed above, the Board has denied service connection for colon cancer, to include as due to Agent Orange exposure. The Veteran is competent to report having erectile dysfunction and psychiatric problems during service and since service. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Veteran's service treatment records do not show treatment for erectile dysfunction or for psychiatric problems. Post-service private and VA treatment records do not specifically show treatment for erectile dysfunction. Such records do show treatment for psychiatric disorders, including diagnoses of anxiety and insomnia. The Board observes that the Veteran has not been afforded VA examinations, with the opportunity to obtain responsive etiological opinions, following a thorough review of the entire claims file, as to his claims for service connection for erectile dysfunction and for a psychiatric disorder, to include depression. Such examinations must be accomplished on remand. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Additionally, as the Veteran's claim for a TDIU rating is inextricably intertwined with his claims for service connection, those matters must be addressed together on remand. Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, the case is REMANDED for the following actions: 1. Ask the Veteran to identify all medical providers who have treated him for erectile dysfunction and psychiatric problems since April 2016. After receiving this information and any necessary releases, obtain copies of the medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise him that he may obtain and submit those records himself. 2. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of his in-service and post-service symptomatology regarding his claimed erectile dysfunction and psychiatric disorder, to include depression. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 3. Thereafter, schedule the Veteran for an appropriate VA examination to determine the nature and likely etiology of his claimed erectile dysfunction. The entire claims file, to include all electronic files, must be reviewed by the examiner. The examiner must specifically indicate if the Veteran has diagnosed erectile dysfunction. Based on a review of the claims file, examination of the Veteran, and generally accepted medical principles, the examiner must provide a medical opinion, with adequate rationale, as to whether it is as at least as likely as not that any currently diagnosed erectile dysfunction is etiologically related to or had its onset during his period of service, to include presumed Agent Orange exposure during service. The examiner must specifically acknowledge and discuss any reports by the Veteran of erectile dysfunction during service and since service. The examination report must include a complete rationale for all opinions expressed. 4. Schedule the Veteran for an appropriate VA examination, to determine if he suffers from PTSD as a result of a verified stressor, or from any other psychiatric disorders related to service. The entire claims file, including any electronic files, must be reviewed by the examiner. The examiner must clearly identify each psychiatric disability found to be present (to include depression and anxiety, etc.), and a diagnosis of PTSD must be ruled in or excluded. The examiner must opine as to whether it is at least as likely as not that any currently diagnosed psychiatric disorders (to include depression and anxiety, etc.), are etiologically related to the Veteran's period of service. The examiner must specifically acknowledge and discuss any reports by the Veteran that he suffered from psychiatric problems during service and since service. The examination report must include a complete rationale for all opinions expressed. 5. Finally, readjudicate the issues on appeal. If the benefits sought remain denied, issue a supplemental statement of the case and return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims 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). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs