Citation Nr: 1803124 Decision Date: 01/17/18 Archive Date: 01/29/18 DOCKET NO. 11-05 660A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Whether new and material evidence has been presented to reopen the claim of entitlement to service connection for a ruptured right ear drum. 2. Whether new and material evidence has been presented to reopen the claim of entitlement to service connection for peripheral neuropathy of the right upper extremity. 3. Whether new and material evidence has been presented to reopen the claim of entitlement to service connection for peripheral neuropathy of the left upper extremity. 4. Whether new and material evidence has been presented to reopen the claim of entitlement to service connection for a right knee disability. 5. Whether new and material evidence has been presented to reopen the claim of entitlement to service connection for a left knee disability. 6. Whether new and material evidence has been presented to reopen the claim of entitlement to service connection for a left forearm scar. 7. Entitlement to service connection for a ruptured right ear drum. 8. Entitlement to service connection for a ruptured left ear drum. 9. Entitlement to service connection for peripheral neuropathy of the right upper extremity, to include as secondary to diabetes mellitus type II. 10. Entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as secondary to diabetes mellitus type II. 11. Entitlement to service connection for a right knee disability. 12. Entitlement to service connection for a left knee disability. 13. Entitlement to service connection for a left forearm scar. 14. Entitlement to service connection for a traumatic brain injury (TBI). 15. Entitlement to service connection for residuals of a broken nose. 16. Entitlement to service connection for a low back disability. 17. Entitlement to service connection for a urinary condition. 18. Entitlement to service connection for status post right carpal tunnel release, to include as secondary to diabetes mellitus type II. 19. Entitlement to service connection for left carpal tunnel syndrome, to include as secondary to diabetes mellitus type II. 20. Entitlement to service connection for a left hip disability, to include as secondary to a low back disability. REPRESENTATION Veteran represented by: Georgia Department of Veterans Services ATTORNEY FOR THE BOARD Mike A. Sobiecki, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Navy from November 1968 to January 1973. His service included deployment to the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from June 2009 and October 2010 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. In January 2011 and August 2015, the Veteran testified before a Decision Review Officer (DRO) at informal conferences at the RO in Portland, Oregon; copies of the informal conference reports are of record. In his March 2011 and July 2016 substantive appeals (via VA Form 9), the Veteran requested a hearing before a Veterans Law Judge (VLJ); however, in a March 2017 VA Form 21-4138, prior to the date of the hearing, he withdrew his hearing request. 38 C.F.R. § 20.704(e) (2017). The appeal previously contained claims of entitlement to service connection for residuals of a gunshot wounds to the right knee and the left shin. In a May 2016 rating decision, the RO granted these claims. They are no longer before the Board. In a May 2017 decision, the Board remanded the claim of entitlement to service connection for a left hip disability because it was inextricably intertwined with the claim of entitlement to service connection for a low back disability, which was not before the Board. Both claims are now before the Board and may be considered herein. No other claims currently before the Board have previously been the subject of prior Board decisions. The issues of entitlement to service connection for a ruptured right eardrum, peripheral neuropathy of the right and left upper extremity, right and left knee disabilities, a left forearm scar, a low back disability, status post right carpal tunnel release, left carpal tunnel syndrome, and a left hip disability are addressed in the REMAND portion of the decision below and are REMANDED to the agency of original jurisdiction (AOJ). FINDINGS OF FACT 1. Service connection for a ruptured right eardrum was initially denied in a June 2004 rating decision on the basis that the condition was neither incurred in nor caused by military service. The Veteran timely filed a notice of disagreement, placing the issue into appellate status; however, in an August 2006 VA Form 21-4138 he withdrew the appeal of the issue. Accordingly, the June 2004 rating decision became final. 2. Evidence received since the June 2004 denial was not previously considered by agency decision makers; is not cumulative and redundant of evidence already of record; relates to unestablished facts; and raises a reasonable possibility of substantiating his claim of service connection for a ruptured right ear drum. 3. Claims of entitlement to service connection for peripheral neuropathy, a right knee disability, a left knee disability, and a left forearm scar were initially denied in a June 2004 rating decision. The basis for each of denial was that the relevant condition was neither incurred in nor caused by military service. The Veteran appealed each denial, and the claims were denied for the same reason in a January 2008 statement of the case. The appeal of these issues was not perfected to the Board and the June 2004 decision became final. 4. Evidence received since the June 2004 denial was not previously considered by agency decision makers; is not cumulative and redundant of evidence already of record; relates to unestablished facts; and raises a reasonable possibility of substantiating his claims of service connection for peripheral neuropathy of the right and left upper extremities, right and left knee disabilities, and a left forearm scar. 5. The evidence does not show that the Veteran has a current disability of a ruptured left ear drum, TBI, or residuals of a broken nose. 6. The evidence does not show that the Veteran's current urinary conditions were incurred in or are otherwise related to his active service. CONCLUSIONS OF LAW 1. The criteria for reopening the claim of entitlement to service connection for a ruptured right ear drum have been met. 38 U.S.C. § 5108 (2014); 38 C.F.R. § 3.156 (2017). 2. The criteria for reopening the claim of entitlement to service connection for peripheral neuropathy of the right upper extremity have been met. 38 U.S.C. § 5108 (2014); 38 C.F.R. § 3.156 (2017). 3. The criteria for reopening the claim of entitlement to service connection for peripheral neuropathy of the left upper extremity have been met. 38 U.S.C. § 5108 (2014); 38 C.F.R. § 3.156 (2017). 4. The criteria for reopening the claim of entitlement to service connection for a right knee disability have been met. 38 U.S.C. § 5108 (2014); 38 C.F.R. § 3.156 (2017). 5. The criteria for reopening the claim of entitlement to service connection for a left knee disability have been met. 38 U.S.C. § 5108 (2014); 38 C.F.R. § 3.156 (2017). 6. The criteria for reopening the claim of entitlement to service connection for a left forearm scar have been met. 38 U.S.C. § 5108 (2014); 38 C.F.R. § 3.156 (2017).. 7. The criteria for service connection for a ruptured left eardrum have not been met. 38 U.S.C. §§ 1110, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303 (2017). 8. The criteria for service connection for a TBI have not been met. 38 U.S.C. §§ 1110, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303 (2017). 9. The criteria for service connection for residuals of a broken nose have not been met. 38 U.S.C. §§ 1110, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303 (2017). 10. The criteria for service connection for a urinary condition have not been met. 38 U.S.C. §§ 1110, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). I. New and Material Evidence The Secretary must reopen a finally disallowed claim when new and material evidence is presented or secured with respect to that claim. 38 U.S.C. § 5108 (2014); 38 C.F.R. § 3.156 (2017). New evidence means existing evidence not previously submitted to agency decision makers. 38 C.F.R. § 3.156(a). Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. Id. A. Ruptured Right Eardrum Service connection for a ruptured right eardrum was denied in a June 2004 rating decision on the basis that the condition was neither incurred in nor caused by military service. The Veteran timely filed a notice of disagreement, placing the issue into appellate status; however, in an August 2006 VA Form 21-4138 he withdrew the appeal of the issue. Accordingly, the June 2004 rating decision became final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. Since the last prior denial in June 2004, the Veteran testified before a DRO and asserted that his ruptured ear drums were caused by diving while on active duty. For the purposes of considering a request to reopen a previously denied claim, the credibility of this evidence is presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). As this statement was not before VA at the time of the prior denial in June 2004, it is new. As it supports that the Veteran's condition may be related to his active service, it is material to the claim. Accordingly, new and material evidence has been received. The request to reopen the claim of entitlement to service connection for a ruptured right eardrum is granted. 38 C.F.R. § 3.156(a); Shade v. Shinseki, 24 Vet. App. 110 (2010). Prior adjudicative actions by the RO did not consider the new evidence on the merits. At this point, a decision on the merits would prejudice the Veteran. Hickson v. Shinseki, 23 Vet. App. 394 (2010). Accordingly, the reopened claim will be further discussed in the REMAND portion of the decision below. B. Peripheral Neuropathy of the Right and Left Upper Extremities Service connection for peripheral neuropathy - encompassing all extremities - was denied in a June 2004 rating decision on the basis that the condition was neither incurred in nor caused by military service. The Veteran appealed, and the claim was denied for the same reason in a January 2008 statement of the case (SOC). The appeal was not perfected to the Board and it became final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. New and material evidence was not received prior to the expiration of the appeal period. 38 C.F.R. § 3.156(b). Since the prior June 2004 denial, the Veteran underwent a VA examination in November 2009. The examination report provides a diagnosis of neuropathy of the upper extremities, primarily hands. The examiner also suggested that the neuropathy may be related to his service-connected diabetes, at least in part. As this evidence was not before VA at the time of the prior denial, it is new. As this evidence provides a current diagnosis for the claims and discusses causal nexus, facts which were not previously established at the time of the June 2004 denial, it is also material. Accordingly, new and material evidence has been received. The requests to reopen the claims of entitlement to service connection for peripheral neuropathy of the right and left upper extremities is granted. 38 C.F.R. § 3.156(a); Shade, supra. Prior adjudicative actions by the RO did consider the new evidence on the merits; however, further development of these claims is necessary to allow the Board to make a fully informed decision. Accordingly, the reopened claims will be further discussed in the REMAND portion of the decision below. C. Right and Left Knee Disabilities Claims of entitlement to service connection for right and left knee disabilities were denied in a June 2004 rating decision on the basis that the conditions were neither incurred in nor caused by military service. The Veteran appealed, and the claims were denied for the same reason in a January 2008 SOC. The appeals were not perfected to the Board and they became final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. New and material evidence was not received prior to the expiration of the appeal period. 38 C.F.R. § 3.156(b). Since the prior June 2004 denial, the Veteran submitted medical treatises discussing the effects of diving on the human body and a private treatment record (7/16/2008) authored by Dr. E.H. that indicates the Veteran's shoulder pains may be related to decompression illness caused by diving during active service. It is the Veteran's contention that the logic of the doctor's rationale is applicable to all of his joint-related claims for service connection. See generally December 2009 VA Form 21-4138 and August 2015 DRO informal conference; see Justus, supra. As this evidence was not previously before VA at the time of the prior June 2004 denial, it is new. As the evidence helps establish a nexus between the current right and left knee disabilities and the Veteran's in-service diving, it is material to the claims. Accordingly, new and material evidence has been received. The requests to reopen the claims of entitlement to service connection for right and left knee disabilities is granted. 38 C.F.R. § 3.156(a); Shade, supra. Prior adjudicative actions by the RO did consider the new evidence on the merits; however, further development of these claims is necessary to allow the Board to make a fully informed decision. Accordingly, the reopened claims will be further discussed in the REMAND portion of the decision below. D. Left Forearm Scar Service connection for a left forearm scar was denied in a June 2004 rating decision on the basis that the condition was neither incurred in nor caused by military service. The Veteran appealed, and the claim was denied for the same reason in a January 2008 SOC. The appeal was not perfected to the Board and it became final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. New and material evidence was not received prior to the expiration of the appeal period. 38 C.F.R. § 3.156(b). Since the prior June 2004 denial, the Veteran testified before a DRO at an informal conference in August 2015. The Veteran indicated that his left forearm got cut in an altercation during service. For the purposes of considering a request to reopen a previously denied claim, the credibility of this evidence is presumed. See Justus, supra. As this statement was not before VA at the time of the prior denial in June 2004, it is new. As it supports that the Veteran's condition may be related to his active service, it is material to the claim. Accordingly, new and material evidence has been received. The request to reopen the claim of entitlement to service connection for a left forearm scar. 38 C.F.R. § 3.156(a); Shade, supra. Prior adjudicative actions by the RO did not consider the new evidence on the merits. At this point, a decision on the merits would prejudice the Veteran. Hickson, 23 Vet. App. at 394. Accordingly, the reopened claim will be further discussed in the REMAND portion of the decision below. II. Service Connection A. Ruptured Left Ear Drum The Veteran seeks service connection for a ruptured left ear drum. For the reasons that follow, the Board finds that service connection is not warranted. The Veteran reported that his ruptured left ear drum is due to diving. August 2015 DRO informal conference report. The Board notes that a September 2003 VA Form 21-526 indicates treatment for a ruptured ear drum was received at Subic Bay naval base in the Philippines during service; however, this filing related only to a ruptured right eardrum and did not indicate treatment was received for the left eardrum. The Veteran's service treatment records (STRs) do not show complaints of, treatment for, or a diagnosis of a ruptured left eardrum. Post-service records also do not reveal a diagnosis of a ruptured left ear drum, to include VA audiological examinations he has undergone in the past, see, e.g., May 2004 VA examination report. The Veteran has not received treatment for a ruptured left ear drum. In sum, the evidence does not show that the Veteran has a current disability of a ruptured left ear drum. 38 C.F.R. § 3.303; McLain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). In the absence of proof of a current disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Accordingly, service connection for a ruptured left eardrum is not warranted. B. TBI and Residuals of a Broken Nose The Veteran seeks service connection for a TBI and for residuals of a broken nose. The Board finds that service connection is not warranted for either claim. As the asserted history of both claims is the same, they will be discussed concurrently. The Veteran reported that while completing a dive during service his diving helmet valve jammed. August 2015 DRO informal conference report. He tried multiple times to get it open. Id. He then hit his head and lost consciousness for approximately 20 to 30 seconds. Id. He contends that this event caused a TBI and broke his nose, but he did not seek treatment for these conditions during service. Id. The Veteran's STRs do not document the occurrence of this event, or complaints of, treatment for, or a diagnosis of a TBI or a broken nose. Post-service records also do not reveal a diagnosis of a TBI or a broken nose, or residuals for either condition. The Veteran has not received treatment for either condition. He has also not identified residuals for either condition. In sum, the evidence does not show that the Veteran has a current disability of a TBI or residuals of a broken nose. 38 C.F.R. § 3.303; McLain, 21 Vet. App. at 319; Romanowsky, 26 Vet. App. at 289. In the absence of proof of a current disability, there can be no valid claim. Brammer, 3 Vet. App. at 225. Accordingly, service connection for a TBI and residuals of a broken nose is not warranted. C. Urinary Condition The Veteran seeks service connection for a urinary condition. For the reasons that follow, the Board finds that service connection is not warranted. VA treatment records reveal that the Veteran has experienced gallstones and kidney stones. See, e.g., VA treatment record (4/2/2015). No other urinary-related diagnoses are identified in the record. His medical records do indicate a problem with a decreased urinary stream since the mid-to-late 1990s; however, no specific problem was diagnosed and the condition was not treated. See, e.g., May 2007 VA examination report. The Veteran's STRs reveal that during service he was treated for an acute case of urethritis, due to gonococcus. He was prescribed medication to be taken for five days. The disease was not noted in later STRs or on his January 1973 separation examination. The record does not indicate that the Veteran's current urinary conditions have a causal connection or are associated with his active service, to include treatment for acute urethritis. The Veteran's plain assertion that his current urinary conditions are related to service is insufficient to trigger VA's duty to assist by providing an examination. 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (explaining that something more than an appellant's conclusory, generalized statement is needed to trigger VA's duty to assist by providing a medical examination). Accordingly, there is not a reasonable basis to find that the Veteran's current urinary conditions were incurred in or are otherwise related to his active service. There is no doubt to be resolved; service connection for a urinary condition is not warranted. ORDER The claim of entitlement to service connection for a ruptured right ear drum is reopened; to this limited extent only, the appeal is granted. The claim of entitlement to service connection for peripheral neuropathy of the right upper extremity is reopened; to this limited extent only, the appeal is granted. The claim of entitlement to service connection for peripheral neuropathy of the left upper extremity is reopened; to this limited extent only, the appeal is granted. The claim of entitlement to service connection for a right knee disability is reopened; to this limited extent only, the appeal is granted. The claim of entitlement to service connection for a left knee disability is reopened; to this limited extent only, the appeal is granted. The claim of entitlement to service connection for a left forearm scar is reopened; to this limited extent only, the appeal is granted. Service connection for a ruptured left eardrum is denied. Service connection for a TBI is denied. Service connection for residuals of a broken nose is denied. Service connection for a urinary condition is denied. REMAND I. Reopened Claims for Service Connection A. Ruptured Right Eardrum and Left Forearm Scar Above, the Board reopened the claims of entitlement to service connection for a ruptured right eardrum and a left forearm scar based on the submission of new and material evidence. Prior adjudicative actions by the RO did not consider the new and material evidence relating to each claim on the merits. At this point, a decision on either claim would prejudice the Veteran. Hickson, 23 Vet. App. at 394. Remand is required for initial AOJ consideration of the new and material evidence relating to each claim on the merits. B. Peripheral Neuropathy of the Right and Left Upper Extremities The Veteran seeks service connection for peripheral neuropathy of the right and left upper extremities. He asserts two theories for service connection. First, he contends that a doctor has told him that his peripheral neuropathy of the upper extremities is related to his in-service dives. The Board notes that no document of record shows that a doctor has provided such an opinion. Second, he contends that his peripheral neuropathy of the upper extremities is secondary to his service-connected diabetes mellitus type II. He underwent a VA examination in November 2009. The examiner diagnosed peripheral neuropathy of the upper extremities, primarily hands. The examiner opined: "It is less likely as not that peripheral neuropathy in his hands is related to diabetes mellitus, although there may well be a small contribution to it. However, given that [h]is diabetes mellitus has been generally well controlled, this seems unlikely." The Board notes that he also diagnosed peripheral neuropathy of the lower extremities and provided a favorable linkage opinion relating the condition to service-connected diabetes mellitus type II - service connection for diabetic neuropathy of the lower extremities was subsequently granted based on this opinion. This opinion is inadequate for several reasons. First, it is unclear whether the Veteran has peripheral neuropathy in either upper extremity that is separate and distinct from his carpal tunnel syndrome. As claims of service connection for carpal tunnel syndrome in each upper extremity are pending and on appeal, the diagnoses must be clarified. Second, to the extent that the examiner discussed aggravation, see El Amin v. Shinseki, 26 Vet. App. 136, 139-41 (2013), the opinion is too speculative in nature due to the use of the phrase "although there may well be." See Bloom v. West, 12 Vet. App. 185 (1999). Third, the examiner appeared to reason that because the Veteran's diabetes mellitus type II is generally well-controlled, it does not contribute to the peripheral neuropathy of the upper extremities; and yet, the examiner also found that the Veteran's diabetes mellitus type II was related to the peripheral neuropathy of the lower extremities. The rationale underpinning the first conclusion, therefore, is inconsistent with the second conclusion. Accordingly, remand is required so that the Veteran may be scheduled for a new VA examination to determine the nature and etiology of his peripheral neuropathy of the right and left upper extremities. 38 C.F.R. § 4.2. C. Right and Left Knee Disabilities The Veteran seeks service connection for his right and left knee disabilities. He contends that both knee disabilities are related to his in-service dives. He also contends, in the alternative, that his right knee disability is related to an in-service gunshot wound that caused his meniscus to tear. The Veteran underwent a VA examination in February 2016. The examiner diagnosed degenerative arthritis in both knees and also noted a prior left knee meniscus tear. The examiner opined that each knee disability was less likely than not incurred in or otherwise related to service. For the right knee, the examiner explained that the condition was more likely related to aging and degenerative changes than due to diving or a gunshot wound in service, and it was also noted that the Veteran has not received regular treatment for the knee since service. For the left knee, the examiner explained that the condition was more likely related to the meniscal tear suffered at work in 1996 than due to diving in service. The Board finds that neither rationale is adequate. The examiner essentially wrote that the conditions are less likely than not related to service because they are more likely than not related to something else, without actually providing a rationale underpinning either determination. For the right knee, to the extent that a lack of continuity of treatment post-service may be considered a rationale, the opinion is still inadequate because it fails to consider the record as a whole, to include the Veteran's lay statements and the post-service treatment the Veteran did receive. It is also noted that the Board cannot reject a claim of service connection based on a lack of continuity of treatment. See Savage v. Gober, 10 Vet. App. 488, 495-96 (1997); see Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991) ("regulations require a continuity of symptomatology, not continuity of treatment"). Accordingly, remand is required so that the Veteran may be scheduled for a new VA examination to determine the nature and etiology of his right and left knee disabilities. 38 C.F.R. § 4.2. II. Original Claims of Service Connection A. Low Back Disability and Left Hip Disability The Veteran seeks service connection for a low back disability and a left hip disability. As these claims are potentially related, they will be discussed concurrently. The Veteran asserts that his low back disability is related to his in-service dives, either as due to compression illness or the weight of his diving suit. See, e.g., August 2015 DRO informal conference report. In February 2016, the Veteran underwent a VA examination to determine the nature and etiology of his low back disability. The examiner diagnosed degenerative arthritis, intervertebral disc syndrome, and spinal stenosis. The examiner opined that the disability was less likely than not incurred in or caused by service. The examiner explained that the back condition is degenerative in nature and not likely related to diving. It was also noted that the Veteran has not established a clear back injury in service. While there is no reasons-or-bases requirement imposed upon medical examiners, their reports must nonetheless contain clear conclusions, supporting data, and a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); see Stefl v. Nicholson, 21 Vet. App. 120 (2007) (the explanations should be of sufficient detail to allow the Board to make a fully informed decision). Here, the Board finds the opinion is inadequate because it is conclusory and did not consider the lay evidence of record. It does not allow for a fully informed decision. Accordingly, remand is required so that the Veteran may be scheduled for a new VA examination to determine the nature and etiology of his low back disability. 38 C.F.R. § 4.2. With regard to the claim of entitlement to service connection for a left hip disability, a January 2011 VA examination report indicates that this disability is related to the low back disability. Thus, if service connection is granted for the low back disability, then service connection will also be warranted for the left hip disability based on a secondary theory of entitlement. See 38 C.F.R. § 3.310. Accordingly, the claims are inextricably intertwined. Harris v. Derwinski, 1 Vet. App. 180 (1991). Adjudication of the claim of entitlement to service connection for a left hip disability is deferred. B. Status Post Right Carpal Tunnel Release and Left Carpal Tunnel Syndrome The Veteran seeks service connection for status post right carpal tunnel release and left carpal tunnel syndrome. The Veteran contends that these conditions are related to his in-service dives or, alternatively, that they are secondary to his service-connected diabetes mellitus type II. As discussed above, a November 2009 VA examination report leaves unclear if these disabilities are separate and distinct from his claimed peripheral neuropathy of the bilateral upper extremities. On remand, the Board is ordering that the Veteran be scheduled for a new VA examination to determine the nature and etiology of the peripheral neuropathy of the bilateral extremities; that examiner should consider the nature and etiology of the carpal tunnel syndromes, as well. Accordingly, the case is REMANDED for the following actions: 1. Obtain and associate with the claims file any outstanding VA treatment records. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of his peripheral neuropathy of the upper extremities and carpal tunnel syndrome. If possible, the examination should be conducted by a neurologist. The examiner must review the entire claims file, to include a copy of this REMAND, in conjunction with the examination. The examiner is asked to provide responses to the following: (A) Does the Veteran have a current diagnosis of peripheral neuropathy of the right and left upper extremities? If so, is it separate and distinct from the carpal tunnel syndromes in each hand/wrist? A complete rationale must be provided, regardless of the answer. (B) For each diagnosed condition, is it at least as likely as not (a 50 percent or greater probability) that it was incurred in or is otherwise related to active service? To be clear, if there are separate and distinct diagnoses of peripheral neuropathy in each upper extremity, then four opinions should be provided: one for peripheral neuropathy in the right upper extremity, one for peripheral neuropathy in the left upper extremity, one for status post right carpal tunnel release, and one for left carpal tunnel syndrome. The Veteran's lay assertions should be considered, to include his contentions regarding in-service dives and decompression illness. The medical treatises he submitted concerning the effects of dives on the human body should also be considered. (C) For each diagnosed condition, is it at least as likely as not that it was proximately due to or aggravated by service-connected diabetes mellitus type II? Again, if there are separate and distinct diagnoses of peripheral neuropathy in each upper extremity, then four opinions should be provided. The examiner should recognize that this question requires two separate opinions (for each disability): one for proximate causation and a second for aggravation. The term "aggravation" means a permanent worsening of a disability beyond its natural progression. If aggravation is found, then, to the extent possible, the examiner should attempt to establish a baseline level of severity for the disability prior to aggravation by diabetes mellitus type II. A complete rationale must be provided for all opinions expressed. The rationale should consider the pertinent evidence of record, to include the Veteran's statements. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of his right and left knee disabilities. The examiner must review the entire claims file, to include a copy of this REMAND, in conjunction with the examination. The examiner must answer the following: For each diagnosed disability, is it at least as likely as not (a 50 percent or greater probability) that it was incurred in or is otherwise related to active service? To be clear, two separate opinions are required: one for the right knee and one for the left knee. The Veteran's lay assertions should be considered, to include his contentions regarding in-service dives and decompression illness. The medical treatises he submitted concerning the effects of dives on the human body should also be considered. Regarding the right knee, the examiner should consider the contention that an in-service gunshot tore his meniscus; however, the examiner should also be aware that private medical records show he underwent a right knee meniscectomy in 1995. (He underwent a meniscectomy for the left knee in 1996.) A complete rationale must be provided for all opinions expressed. The rationale should consider the pertinent evidence of record. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of his low back disability. The examiner must review the entire claims file, to include a copy of this REMAND, in conjunction with the examination. The examiner must address whether it is at least as likely as not (a 50 percent or greater probability) that the current low back disability was incurred in or is otherwise related to active service? The Veteran's lay assertions should be considered, to include his contentions regarding in-service dives, decompression illness, and the weight of his dive suit. The medical treatises he submitted concerning the effects of dives on the human body should also be considered. A complete rationale must be provided for all opinions expressed. The rationale should consider the pertinent evidence of record. 5. Finally, readjudicate the appeal. If any of 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 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 or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112. ______________________________________________ D. JOHNSON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs