Citation Nr: 1802582 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 12-23 202 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for a neck disability. 3. Entitlement to service connection for a cardiovascular disability, to include residuals of a myocardial infarction (MI) and ventricular arrhythmias. 4. Entitlement to service connection for a bilateral foot disability, to include as secondary to a back disability. 5. Entitlement to service connection for diabetes mellitus, to include as due to exposure to herbicide agents/Agent Orange. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD William Skowronski, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from September 1970 to April 1972. This matter is before the Board of Veterans' Appeals (Board) on appeal from July 2009 and July 2012 rating decisions by the Chicago, Illinois Department of Veterans Affairs (VA) Regional Office (RO). The July 2009 rating decision denied service connection for neck, back, heart, and bilateral foot disabilities. The July 2012 rating decision, in pertinent part, denied service connection for diabetes mellitus. In March 2015, a Travel Board hearing was held before the undersigned; a transcript is in the record. In October 2015, the Board remanded the claim for additional development. The matter of service connection for a cardiovascular disability is being REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if action on his part is required. FINDINGS OF FACT 1. The Veteran's low back disability was not manifested in service or within a year following his discharge from active duty, and the preponderance of the evidence is against a finding that it is etiologically related to his service. 2. The Veteran's neck disability was not manifested in service or within a year following his discharge from active duty, and the preponderance of the evidence is against a finding that it is etiologically related to his service. 3. A right or left foot disability was not manifested in service, and the preponderance of the evidence is against a finding that any such disability is etiologically related to his service or caused or aggravated by a service-connected disability. 4. The Veteran's diabetes mellitus was not manifested in service or within a year following his discharge from active duty, and the preponderance of the evidence is against a finding that it is etiologically related to his service; he did not serve in Vietnam during the Vietnam era, and is not shown to have otherwise been exposed to Agent Orange/herbicide agents during service. CONCLUSIONS OF LAW 1. Service connection for a low back disability is not warranted. 38 U.S.C. §§ 1110, 1112, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). 2. Service connection for a neck disability is not warranted. 38 U.S.C. §§ 1110, 1112, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). 3. Service connection for a bilateral foot disability is not warranted. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2017). 4. Service connection for diabetes mellitus is not warranted. 38 U.S.C. §§ 1110, 1112, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. VA's duty to notify was satisfied by correspondence in April 2009 and April 2012. The AOJ did not arrange for VA examinations in connection with the claims of service connection for a low back and bilateral foot disabilities, and did not seek a medical advisory opinion regarding the etiology of the Veteran's diabetes mellitus. Such examinations and opinion are not needed because the record does not contain any evidence suggesting there may be a link between the Veteran's variously diagnosed low back disability, bilateral foot disability, or diabetes mellitus and his active duty service. He contends his low back disability is related to an injury sustained in service. However, as will be further explained below, the Board finds his reports of an injury in service and persisting back pain since are not credible, as they are contradicted by contemporaneous clinical notations and by his own more contemporaneous reports . Pursuant to the October 2015 remand, the AOJ sought records of private treatment for a low back disability (and the claimed neck disability) the Veteran reported he received prior to seeking VA treatment for such disabilities. While the available records were received, they do not show or suggest he has had back pain since service. He contends his bilateral foot disability is secondary to the claimed low back disability, and has not alleged it is related directly to his service. He alleges his diabetes mellitus is due to exposure to Agent Orange or other herbicide agents in service, but such exposure is not shown. In September 2016, the AOJ made a formal finding that there was insufficient evidence to concede he was exposed to Agent Orange or other herbicide agents. Absent any competent (medical) evidence suggesting that such disabilities might be related to his service, examinations to secure medical nexus opinions are not necessary, as even the low threshold standard (as to when an examination is needed) endorsed by the U.S. Court of Appeals for Veterans Claims (CAVC) in McLendon v. Nicholson, 20 Vet. App. 27 (2006), is not met. See 38 C.F.R. § 3.159(c)(4). Neither the Veteran nor her representative has raised any other issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Factual Background Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss every piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as deemed appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. The Veteran's service treatment records (STRs) show he reported he was kicked in the neck in July 1971. On examination, his neck muscles were stiff, and a muscle spasm was noted. On January 1972 service separation examination, the Veteran's endocrine system, feet, lower extremities, and spine were normal on clinical evaluation. March 2006 and August 2006 private hospital records (received in January 2011) indicate the Veteran complained of back pain. He was noted to have a history of diabetes mellitus. Back pain was assessed. A September 2007 VA emergency department note indicates the Veteran complained of low back pain after falling at a train station on the prior day. An acute back strain was diagnosed. He continued to complain of back pain due to that fall in October 2007. A separate October 2007 VA treatment note notes he fell as he was getting up from a chair while giving blood. He reported back pain, but an X-ray showed no acute injury. An October 2007 VA neurology consultation note shows he complained of numbness and tingling in his right hand after he fell and hit his right shoulder, hand, and low back. He denied neck pain, but reported continued back pain. A November 2007 treatment records notes his back pain began two months earlier. A February 2008 treatment record notes he complained of back and neck pain. A March 2008 X-ray revealed cervical spine degenerative joint disease (DJD) and bilateral foraminal stenosis. On February 2008 VA general examination, the Veteran's neck and musculoskeletal system were evaluated as within normal limits. However, he reported DJD had been diagnosed seven years prior to the examination. It was noted to affect multiple joints, including his shoulders and wrists. An April 2008 private treatment record notes the Veteran complained of neck and back pain. April 2008 and May 2008 VA treatment records note the Veteran complained of low back and neck pain. An April 2008 X-ray revealed DJD of the lumbosacral spine. A May 2008 note indicates he reported he had the chronic pain for a year. The pain traveled down his legs. An August 2008 note indicates cervical stenosis and lumbar stenosis were diagnosed. A November 2008 note indicates he reported the back pain began a year earlier. A December 2008 note attributes his back and neck pain to disc problems. An April 2008 Social Security Administration (SSA) examination report notes the Veteran reported having back and neck pain for more than a year. A backache, which was mostly a manifestation of disk disease with radiculopathy, was diagnosed. A December 2008 VA physical medicine rehabilitation consultation note indicates the Veteran reported his back pain began around 2006, after 26 years of truck driving. He denied an acute event such as trauma or heavy lifting initiating the low back pain. A February 2009 pain assessment note indicates he reported the back pain began 4 to 5 years earlier. A March 2009 VA physical therapy note indicates the Veteran complained of low back pain and swelling of his legs and hands. A March 2010 VA mental health note indicates his back pain began in April 2007. In November 2010, the Veteran claimed service connection for diabetes mellitus, contending it is due to exposure to Agent Orange . On March 2011 VA examination, diabetes mellitus was diagnosed. The examiner did not offer an etiology opinion. A June 2011 VA physical medicine rehabilitation consultation note indicates the Veteran complained of pain radiating from his neck and back to his lower extremities and ankles. Degenerative disc disease (DDD), facet arthropathy, and possible myelomalacia were diagnosed. An August 2011 pain consultation report and December 2011 VA neurosurgery consultation report note he reported had been experiencing neck pain for several years. In February 2012, he reported he had been experiencing neck pain for two years. On May 2012 VA cervical spine examination, cervical spine stenosis with herniated disc was diagnosed. The Veteran complained of constant upper back and neck pain. He reported his neck was injured in service after a driver of an armored personnel carrier stopped it suddenly, causing him to strike his neck on the vehicle and be hospitalized for two days. The examiner noted he reviewed the Veteran's claims file and opined his neck disability was not incurred in or caused by the claimed in-service injury. The examiner explained his STRs document a single neck injury from when he was kicked in the neck in July 1971; a muscle spasm was diagnosed, and he did not complain of neck pain on separation. The examiner opined the lack of continued complaints show his muscle spasm resolved. He also noted there was no documented neck complaint for more than 30 years after the Veteran separated from service. A July 2013 VA treatment record notes the Veteran reported his back pain traveled down his legs. An August 2013 VA pain clinic consultation report notes the Veteran reported his neck pain began in service when he was kicked in the neck. A July 2015 treatment record notes a long history of neck pain. A November 2015 treatment record notes he had an eight-year history of neck pain. He reported he was hit in the neck in service and was hospitalized. He reported the pain subsided but then returned about 15 years earlier. At the March 2015 Travel Board hearing, the Veteran testified that after he was kicked in the neck, he had continuing neck pain throughout his following service. He reported he worked as a truck driver after service and that the duties aggravated his neck pain. He reported he did not seek treatment until 1981 at Cook County Hospital because he could not take time off, and that an X-ray at that time showed a disc problem for which a neck collar was prescribed (and relieved the pain until it became worse again in 2003 or 2004). He testified he injured his back during a training exercise in Germany in the summer of 1971 when he fell from a personnel carrier; and was treated in the field with heating pads and pain medication . He noted he was put on light duty. He first sought treatment for his back pain after service in 2003. He reported an X-ray showed dislocated discs in his back. He reported he treated his back pain with over-the-counter medication prior to then. He reported he experienced numbness in his legs and that treatment providers told him problems with his legs and feet are due to the back disability. He contended his diabetes mellitus was related to exposure to Agent Orange used in Germany to kill vegetation for training exercises. In a July 2016 response, the Joint Services Records Research Center (JSRRC) indicated it conducted joint research with the National Archives Records Administration (NARA) but due to the lack of unit records available was unable to document that the Veteran was exposed to Agent Orange or other herbicide agents while training in Germany between April 1971 and June 1972. A July 2016 VA email noted the Department of Defense (DoD) has not identified any location in Germany or Europe where Agent Orange was used, tested, stored, or transported. In September 2016, the AOJ made a formal finding that there was not enough evidence to concede exposure to Agent Orange or other herbicide agents. A December 2016 VA treatment record notes diabetes mellitus was diagnosed in 2010. Legal Criteria Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease initially 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). To substantiate a claim of service connection, there must be evidence of: a present disability (for which service connection is sought); incurrence or aggravation of a disease or injury in service; and a causal relationship between the claimed disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases (including arthritis) may be service connected on a presumptive basis if manifested to a compensable degree in a specified period of time postservice (one year for arthritis). 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. Certain diseases (including diabetes mellitus) may be service connected on a presumptive basis as due to herbicide agent (Agent Orange) exposure in service if manifested in a Veteran who served in the Republic of Vietnam during the Vietnam Era. 38 U.S.C. § 1116; 38 C.F.R. § 3.309(e). Secondary service connection may be established for a disability that is proximately due to, or the result of, or aggravated by a service connected disease or injury. Establishing secondary service connection requires evidence of: (1) A current disability (for which secondary service connection is sought); (2) an already service connected disability; and (3) that the current disability was either (a) caused or (b) aggravated by the service connected disability. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995). The determination as to whether these requirements are met is based on analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). 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 claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Analysis Low back disability It is not in dispute that the Veteran now has low back disability. VA treatment records show DJD, DDD, stenosis, and possible myelomalacia. What he still must show to establish service connection for the variously diagnosed low back disability is that it is etiologically related to his service. There is no evidence that the low back disability manifested in service or in the first postservice year. The Veteran alleges he injured his low back in a fall from an armored personnel carrier in service and that his back pain has persisted since that injury. However, the Board finds such allegation not credible; it is contradicted by contemporaneous clinical recordings and self-serving and (See Pond v. West, 12 Vet. App. 341 (1999)). He did not report such injury and continuity before he filed a claim seeking service connection, and the allegation is inconsistent with his denials of such symptoms on service separation examination and his reports of the back pain beginning after a September 2007 fall and a December 2008 report of back pain beginning in 2006 due to working as a truck driver for 26 years (which by virtue of being more contemporaneous and provided in a clinical context merit greater probative value). Consequently, service connection on the basis that such disability became manifest in service and persisted or on a presumptive basis (for arthritis of the back as a chronic disease under 38 U.S.C.A. § 1112) is not warranted. Furthermore, there is no medical evidence that suggests the variously diagnosed low back disability may be otherwise related to the Veteran's active duty service. The Board has considered the Veteran's general assertions that his low back disability is related to his service. Because he is a layperson, without evidence of onset in service and continuity of symptoms thereafter, he is not competent to opine regarding the etiology of his low back disability; that is a medical question, and it requires medical expertise. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (2007). Accordingly, the Board concludes the preponderance of the evidence is against the claim of service connection for a low back disability, and that the appeal in this matter must be denied. The Board has considered the benefit-of-the-doubt rule; however, since a preponderance of the evidence is against the Veteran's claim , the benefit-of-the-doubt rule is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Neck disability It is not in dispute that the Veteran now has a neck disability. VA treatment records and the May 2012 VA examination report show diagnoses of DJD, DDD, a herniated disc, foraminal stenosis, and possible myelomalacia . What he still must show to establish service connection for the variously diagnosed neck disability is that it is etiologically related to his service. There is no evidence that a chronic neck disability was manifested in service or in the first postservice year. The Veteran has reported his neck pain has persisted since service and that private providers told him he had a disc problem after he sought treatment for neck pain in 1981. However, the Board finds those reports not credible because they are self-serving and contradicted by contemporaneous clinical recordings. See Pond, 12 Vet. App. at 341. While his STRs show he was kicked in the neck in July 1971, a muscle spasm was diagnosed and his spine was clinically evaluated as normal on January 1972 separation examination. An August 2011 pain consultation report and December 2011 VA neurosurgery consultation report note he reported experiencing neck pain for several years. In February 2012, he reported experiencing neck pain for two years. Notably, he only attributed his neck pain to injuries in service after he filed a claim for service connection. Consequently, service connection on the basis that such disability became manifest in service and persisted or on a presumptive basis (for neck arthritis as a chronic disease under 38 U.S.C.§ 1112) is not warranted. A preponderance of the evidence is against finding that the Veteran's variously diagnosed neck disability was manifested in service or is otherwise related to service. The May 2012 VA examiner opined the variously diagnosed neck disability was not incurred in or caused by the claimed injury in service. The examiner explained that a review of STRs found he did not continue to complain of neck pain after a spasm was diagnosed in July 1971, suggesting it resolved prior to separation. The Board places substantial probative value in the May 2012 VA examiner's opinion because it includes rationale that reflects familiarity with the record and cites to supporting factual data. There is no medical opinion in the record to the contrary . In summary, the variously diagnosed neck disability cannot be found to have been incurred during active duty service, and a preponderance of the evidence is against the claim for service connection for a neck disability. The Board has considered the Veteran's own general assertions that his neck disability is related to service. Because he is a layperson, without evidence of chronic disability in service/continuity of complaints thereafter, he is not competent to opine regarding the etiology of his neck disability. That is a medical question, and it requires medical expertise. See Jandreau, 492 F. 3d at 1377. Accordingly, the Board finds that the preponderance of the evidence is against this claim, and that the appeal in the matter must be denied. The Board has considered the benefit-of-the-doubt rule; however, since a preponderance of the evidence is against the Veteran's claim for service connection, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Bilateral foot disability The Veteran has reported his low back pain travels to his feet and that he experiences numbness in his legs. On April 2008 SSA examination, back pain with radiculopathy was diagnosed. However, it is neither shown, nor alleged, that radiculopathy was manifested in service. Therefore, service connection for radiculopathy of the lower extremities on the basis that it became manifest in service and persisted, is not warranted. The Veteran's asserted theory of entitlement to this benefit is one of secondary service connection; he claims he has radiculopathy of the lower extremities due to his low back disability. It is not in dispute that the Veteran's low back disability is the primary etiological factor for his development of radiculopathy manifested by numbness and pain in his lower extremities. However, a threshold legal requirement for substantiating a claim of secondary service connection is that the primary disability to which the claimed disability is alleged to be secondary must be service-connected. See 38 C.F.R. § 3.310. As the determination above affirms the denial of service connection for a low back disability, that threshold requirement is not met. Accordingly, the claim of secondary service connection for a bilateral foot disability lacks legal merit. Hence, the appeal in the matter must be denied. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Diabetes mellitus It is not in dispute that the Veteran now has diabetes mellitus. VA treatment records and a March 2011 VA examination report show a diagnosis of diabetes mellitus. What he must still show to establish service connection for the diabetes mellitus is that it is etiologically related to his service. There is no evidence, or allegation, that the diabetes mellitus manifested in service or in the first postservice year. A December 2016 VA treatment record notes it was first diagnosed in 2010. Consequently, service connection for the disease on the basis that it became manifest in service and persisted or on a presumptive basis (as a chronic disease under 38 U.S.C.§ 1112; 38 C.F.R. § 3.309(a)) is not warranted. What remains then is the question of whether, in the absence of a showing of onset in service and continuity since, the Veteran's diabetes mellitus may somehow otherwise be related to his remote service. The Veteran did not serve in Vietnam, and may not be presumed to have been exposed to herbicide agents in service. He contends he was exposed to herbicide agents during training exercises in Germany. However, after a joint search with the NARA, JSRRC indicated that the alleged exposure to herbicide agents during training in Germany between April 1971 and June 1972 could not be verified. A July 2016 VA e-mail notes that DoD has not identified any location in Germany or Europe where Agent Orange was used, tested, stored, or transported. In September 2016, the AOJ made a formal finding that there was insufficient evidence to concede the Veteran was exposed to Agent Orange or other herbicide agents in the manner alleged. Accordingly, exposure to herbicide agents in Germany is not shown, and service connection based on such exposure is not warranted. There is no competent (medical) evidence in the record that suggests the Veteran's diabetes mellitus may otherwise be related to his active duty service. The Board has considered his own general assertions that his diabetes mellitus is related to service. Because he is a layperson, he is not competent to opine regarding the etiology of diabetes mellitus. That is a medical question that requires medical expertise. See Jandreau, 492 F. 3d at 1377. He does not cite to supporting medical opinion or treatise evidence, and has not expressed a theory of entitlement other than one based on exposure to herbicide agents (which is not supported by the evidentiary record). Accordingly, the Board concludes the preponderance of the evidence is against the claim of service connection for diabetes, and that the appeal in this matter must be denied. ORDER Service connection for a low back disability is denied. Service connection for a neck disability is denied. Service connection for a bilateral foot disability, to include as secondary to a back disability, is denied. Service connection for diabetes mellitus is denied. REMAND The Board finds that further development of the record is again needed for a proper adjudication of the matter of service connection for a cardiovascular disability. The October 2015 Board remand directed the AOJ to secure a medical opinion regarding the nature and etiology of the Veteran's variously diagnosed cardiovascular disability(ies). The examiner was requested to identify by diagnosis each cardiovascular disability shown. On February 2017 VA examination, acute, subacute, or old myocardial infarction was diagnosed. The Veteran reported he had a heart attack in 1971 while stationed in Germany. The examiner noted he was a nurse practitioner, not a cardiologist or internist, and did not provide an etiology opinion. On April 2017 VA examination, the examiner opined that "the records do not support the diagnosis of old myocardial infarction with a high degree of probability (>50%)." The examiner opined the documented sinus tachycardia is not an ongoing or chronic problem, but occurred in a setting of chest pain and was self-limiting. The examiner noted there was no current tachycardia and did not identify any other cardiovascular disabilities as shown. That opinion is not fully responsive to the questions presented and does not reflect contemplation of the entire record. The examiner did not acknowledge and address a November 2011 VA echocardiogram that revealed Grade I diastolic dysfunction and a January 2012 EKG that revealed sinus tachycardia and left ventricular hypertrophy (the significance of which requires explanation). Further development for an opinion that encompasses all evidence, and includes complete rationale, is necessary. On remand, any records of updated treatment for cardiovascular disability should be obtained. The case is REMANDED for the following: 1. The AOJ should secure for association with the record complete clinical records of all updated (from December 2016 to the present) VA evaluations and treatment the Veteran has received for cardiovascular disability (to specifically include the reports of his treatment at Hines VA Medical Center). If any such records are unavailable, the reason for their unavailability must be explained for the record, and the Veteran should be so advised. 2. The AOJ should then arrange for the Veteran to be examined by a cardiologist or internist to determine the nature and likely etiology of his variously diagnosed cardiovascular disability(ies). The Veteran's record (to include this remand and postservice treatment records) must be reviewed by the examiner in conjunction with the examination. Upon review of the record and interview and examination of the Veteran, the examiner should provide opinions that respond to the following: (a) Please identify (by diagnosis) each cardiovascular disability shown, including diastolic dysfunction, sinus tachycardia, and left ventricular hypertrophy and any others identified on examination. (Any testing necessary to determine the nature of a cardiovascular disability should be performed). (b) Please identify the likely etiology for each cardiovascular disability diagnosed? Specifically, is it at least as likely as not (a 50% or better probability) that such disability arose during (was first manifested in, or is otherwise etiologically related to) the Veteran's active service (to include his complaints of, and treatment for, chest pain and rapid heartbeat therein)? The examiner must include rationale with all opinions, to specifically include comment on the opinions/textual evidence already in the record, including the November 2011 VA diagnosis of diastolic dysfunction and January 2012 diagnosis of sinus tachycardia and left ventricular hypertrophy, and the February 2008, March 2011, February 2017, and April 2017 VA examination reports. The examiner should also discuss/explain the nature, features, and etiology of tachycardia, to include whether it is an acute (or may be a chronic) condition, whether it is a factor in the development of cardiovascular pathology, and whether or not a current tachycardia may be entirely dissociated from tachycardia noted during remote service (and if so, the basis for doing so). If a cardiovascular disability is determined to be unrelated to the Veteran's service, the examiner should identify the etiology considered more likely. 3. The AOJ should then review the entire record and readjudicate the claim of service connection for a cardiovascular disability. If it remains denied, the AOJ should issue an appropriate supplemental statement of the case, afford the Veteran and his representative opportunity to respond, and return the case to the Board. The Veteran 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 for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ GEORGE R. SENYK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs