Citation Nr: 1804015 Decision Date: 01/23/18 Archive Date: 01/31/18 DOCKET NO. 17-08 895 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 10 percent for a cervical spine disorder. 2. Entitlement to an initial compensable rating for bilateral hearing loss. 3. Whether new and material evidence has been received sufficient to reopen a claim for entitlement to service connection for hypertension. 4. Entitlement to service connection for hypertension. 5. Whether new and material evidence has been received sufficient to reopen a claim for entitlement to service connection for left wrist carpel tunnel syndrome. 6. Whether new and material evidence has been received sufficient to reopen a claim for entitlement to service connection for a disability manifested by shortness of breath, also claimed as chronic obstructive pulmonary disease (COPD), including as due to asbestos. 7. Entitlement to service connection for a disability manifested by shortness of breath, also claimed as COPD, including as due to exposure to asbestos. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his Wife ATTORNEY FOR THE BOARD A. Parrish, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1959 to February 1963 and from April 1972 to April 1988. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In October 2017, the Veteran and his wife testified at a hearing before the undersigned Veterans Law Judge. A copy of the proceedings is associated with the electronic claims file. The Board notes that in October 2017, the Veteran's representative submitted an Application for Disability and Compensation and Related Compensation Benefits, Form 21-526EZ, which listed the Veteran's disability being claimed as "entitlement to service connection for carpel tunnel syndrome. CUE diagnosed and treated in service." However, to the extent that such statement is asserting clear and unmistakable error (CUE), the Board points out that the form submitted does not identify a final rating decision which is being claimed to have been clearly and unmistakably erroneous. See 38 C.F.R. § 3.105 (2017). Accordingly, the Board will proceed with the adjudication of the claim on appeal as reflected on the title page of this decision. The Board notes that the Veteran remains free to file a motion for CUE concerning any prior final rating decision. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The issues of a rating in excess of 10 percent for a cervical spine disorder, an initial compensable rating for bilateral hearing loss, whether new and material evidence has been received sufficient to reopen a claim for entitlement to service connection for left wrist carpel tunnel syndrome, and entitlement to service connection for a disability manifested by shortness of breath, also claimed as COPD, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACTS 1. In a final August 1989 rating decision, the RO denied the Veteran's claims for service connection for hypertension and a disability manifested by shortness of breath, also claimed as COPD. 2. The evidence received since the August 1989 rating decision is not cumulative or redundant of the evidence of record and raises a reasonable possibility of substantiating the Veteran's claim of entitlement to service connection for hypertension and a disability manifested by shortness of breath, also claimed as COPD. 3. Hypertension was not shown in active service or for many years thereafter, and the only medical opinion of evidence to address the etiology of hypertension weighs against the claim. CONCLUSIONS OF LAW 1. The August 1989 rating decision that denied the Veteran's claim for service connection for hypertension and a disability manifested by shortness of breath, also claimed as COPD, is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.302, 20.1103 (2017). 2. New and material evidence has been received to reopen the claim for entitlement to service connection for hypertension and a disability manifested by shortness of breath, also claimed as COPD. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156(a) (2017). 3. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107 (2012); 38 C.F.R. 3.102, 3.303, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 (2017). Neither the Veteran nor his representative has raised any 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 a duty to assist argument). New and Material Evidence The Board must consider the question of whether new and material evidence has been received because it goes to the Board's jurisdiction to reach the underlying claim and adjudicate the claim de novo. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). If the Board finds that no new and material evidence has been offered, that is where the analysis must end. Butler v. Brown, 9 Vet. App. 167 (1996). New evidence is evidence not previously submitted to agency decision makers. Material evidence is evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2017). In determining whether new and material evidence has been received, VA must initially decide whether evidence associated with the claims file since the prior final denial is new. That analysis is undertaken by comparing newly received evidence with the evidence previously of record. After evidence is determined to be new, the next question is whether it is material. The Board must review all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened. Evans v. Brown, 9 Vet. App. 273 (1996). For purposes of determining whether new evidence is material, the credibility of the new evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). New and material evidence is not required as to each previously unproven element of a claim. Shade v. Shinseki, 24 Vet. App. 110 (2010). The Board notes that its task is to first decide whether new and material evidence has been received, as opposed to whether or not the evidence actually substantiates the Veteran's claim. Historically, an August 1989 rating decision denied a claim for service connection for hypertension and a disability manifested by shortness of breath, also claimed as COPD, on the basis that the Veteran did not have such disabilities or that such disabilities were not shown by the evidence to be incurred in or aggravated by the Veteran's service. The Veteran did not appeal that decision and it is now final. 38 U.S.C. § 7104 (2012). In June 2011, the Veteran sought to reopen his claims. VA may reopen and review a claim that has been previously denied if new and material evidence is submitted by or on behalf of a Veteran. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156(a) (2017); Hodge v. West, 155 F. 3d 1356 (Fed. Cir. 1998). Pertinent evidence added to the record since the final August 1989 RO decision include statements from the Veteran, VA medical records, private treatment records, the Veteran and his wife's hearing testimony, and previously submitted service treatment records (STRs). A February 2013 VA examination found that the Veteran had a diagnosis of hypertension. The examiner noted that the Veteran's exact date of diagnosis of hypertension was not documented. Consequently, as the prior denial of the Veteran's claim for service connection for hypertension was based on the lack of existence of the disability and such a disability has now been established, the claim of entitlement to service connection for hypertension is reopened. In regards to the Veteran's claim for a respiratory disability, a June 2012 private medical record indicated that the Veteran had "early or mild COPD." Consequently, as the prior denial determined that the Veteran did not have a respiratory disability or that such a disability was incurred in or aggravated by service and the existence of the disability has been established, the Board finds that the claim for entitlement to service connection for a disability manifested by shortness of breath, also claimed as COPD, is reopened, on the finding of "early or mild COPD" in the June 2012 private medical record and remanded for further development, as discussed below. Hypertension Service connection may be granted for disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. § 1131 (2012); 38 C.F.R. § 3.303 (2017). That determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d) (2017). Service connection may be presumed for certain chronic diseases, to include hypertension, which develop to a compensable degree within one year after discharge from service, even though there is no evidence of such disease during the period of service. That presumption is rebuttable by probative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137 (2012); 38 C.F.R. 3.307, 3.309(a) (2017). Where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has that chronic disability, service connection can be granted. That does not mean that any manifestations in service will permit service connection. To show chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time as distinguished from merely isolated findings or a diagnosis including the word chronic. When the disease entity is established, there is no requirement of evidentiary showing of continuity. 38 C.F.R. § 3.303(b) (2017). If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptoms after service may serve as an alternative method of establishing service connection. 38 C.F.R. § 3.303(b) (2017). Continuity of symptoms may be established if a claimant can demonstrate (1) that a condition was noted during service; (2) evidence of post- service continuity of the same symptomatology and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. Continuity of symptoms applies only to those conditions explicitly recognized as chronic. 38 C.F.R. § 3.309(a) (2017); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). At the outset, the Board notes that VA regulations specify that the term hypertension means that the diastolic blood pressure is predominantly 90 mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm or greater with a diastolic blood pressure of less than 90 mm. 38 C.F.R. § 4.104, Diagnostic Code 7101. In addition, VA regulations specify that hypertension must be confirmed by readings taken two or more times on at least three different days. Id., Note (1). In February 1959, an enlistment report of medical history STR indicated the Veteran did not report any symptoms or concerns regarding hypertension or his vascular system. A concurrent report of medical examination also did not find any symptoms or concerns regarding the Veteran's vascular health. His blood pressure was recorded at 112/78. His January 1963 separation examination also found no symptoms or complaints regarding his blood pressure or vascular health; his blood pressure was 120/76. In an April 1972 report of medical history, the Veteran did not indicate any symptoms or concerns regarding hypertension or his vascular system. In September 1976, an STR recorded the Veteran's blood pressure at 120/70. An October 1979 STR recorded the Veteran's blood pressure at 120/70. A November 1985 STR showed the Veteran's blood pressure to be 126/85. In February 1986, an STR indicated the Veteran reported to the clinic for a bee sting kit due to a bee sting allergy. His blood pressure was recorded at 146/96. He denied a history of hypertension. He was recommended for follow-up for a high blood pressure reading. His blood pressure over the course of three days was 126/82, 142/88, and 132/90. A September 1986 STR showed the Veteran's blood pressure to be 120/80. A February 1987 STR showed the Veteran's blood pressure to be 120/72. A May 1987 STR indicated the Veteran's blood pressure was 148/84. He reported to the clinic for reports of a scratchy feeling in his eye. In July 1987, an STR showed the Veteran's blood pressure to be 128/88. An August 1987 STR recorded the Veteran's blood pressure to be 128/96. He reported for PRT screening. He was cleared for PRT and advised to do a follow-up blood pressure test in the next week. In September 1987, the Veteran's blood pressure was recorded as 126/81. A separate September 1987 STR indicated the Veteran's blood pressure was 135/86. In March 1988, a STR showed the Veteran to have a blood pressure of 110/70. In his April 1988 retirement examination, no symptoms or concerns regarding hypertension or the Veteran's vascular system were noted or found. His blood pressure was 120/82. In his concurrent report of medical history, the Veteran did indicate he had high or low blood pressure. He stated that it was not excessive, but occasionally high. A December 1988 VA medical record indicated the Veteran's blood pressure was 136/80. In January 1989, a VA Report of Medical Examination form indicated the Veteran stated that he was told he had borderline hypertension from several examinations. His blood pressure that date was 136/80, 140/90, and 138/90. He stated that he had never been treated for hypertension. Upon examination, it was noted that the Veteran had occasional episodes of elevation of blood pressure on physical tests. In March 2011, a VA medical center note indicated the Veteran had blood pressure readings of 173/93 and 176/84. As previously stated, a February 2013 VA examination found that the Veteran had a diagnosis of hypertension. The Veteran reported that his last few years in-service his blood pressure would be around 140 over 90 and continued to escalate. The Veteran reported that he began taking medication for hypertension 12 to 14 years ago and that his blood pressure was controlled on medication. During the examination, the Veteran's blood pressure was 150/88, 157/82, and 172/80. The examiner noted the Veteran had several isolated borderline high blood pressure readings. The examiner stated that the Veteran's hypertension was less likely than not incurred in or caused by the high blood pressure readings shown on active duty. The examiner opined that the Veteran had a few elevated blood pressure readings in which were subsequently resolved as noted by follow-up blood pressure monitoring. The examiner found that there was no objective evidence of sustained hypertension during active duty or within two years of retirement from active duty. The examiner also noted that the Veteran stated he began taking blood pressure medication 12 to 14 years ago, but had retired from service over 25 years prior. In his October 2017 hearing testimony, the Veteran stated he had been taking hypertension medication for 30 years, a few years after he separated from service. Direct service connection necessitates that the Veteran's hypertension was related to an injury or disease incurred in service. The evidence of record, however, does not support such a finding. The Veteran's STRs do contain reports of the Veteran having elevated blood pressure readings, but also show the Veteran to have had predominantly normal blood pressure readings while in-service. Importantly, the Veteran's STRs are void of treatment for high blood pressure as a stand-alone concern and also do not include a diagnosis of or treatment for hypertension. Thus, the Veteran's isolated episodes of elevated blood pressure in-service do not establish that the Veteran had hypertension while in-service. In his April 1988 separation physical, hypertension was not found to have been present while the Veteran was in-service. Also, in his retirement report of medical history, the Veteran indicated he had occasional high blood pressure readings, but did not indicate that he had hypertension. His notation of occasional high blood pressure readings were related to prior episodes and the Board notes that the Veteran had normal blood pressure readings in the subsequent blood pressure checks. The December 1988 VA record and the January 1989 examination also indicated that the Veteran had elevated blood pressure readings but did not find a diagnosis of hypertension while in-service or diagnose the Veteran with hypertension at that time. Additionally, the Veteran's February 2013 VA examiner opined that his hypertension was not related to, incurred in or aggravated by his active service. The examiner noted the Veteran's occurrences of in-service elevated readings, but found them to be isolated occurrences rather than indicative of evidence of hypertension while in-service. Similarly, there is no evidence of record which established that the Veteran was diagnosed with hypertension within one year of his active service. His December 1998 and January 1989 VA medical record and examination indicated that he did not have nor had been diagnosed with hypertension. Furthermore, the first documented report of hypertension found in the evidence of record was in March 2011, when he presented with hypertension. This medical record did not indicate that the Veteran had related his hypertension to service or had been treating for hypertension since his separation from service. The first indication contained in the evidence of record that the Veteran had hypertension, then, was the March 2011 VAMC note which indicated he was treating for hypertension. Additionally, in the February 2013 VA examination, the Veteran reported that he was put on high blood pressure medication 12 to 14 years prior, over a decade after his active service. Thus, the Veteran's hypertension, by his own statement, was not treated until over a decade after his active service had ended. The passage of many years between discharge from active service and the documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson v. Gober, 230 F. 3d 1330 (Fed. Cir. 2000); Shaw v. Principe, 3 Vet. App. 365 (1992). Thus, the medical evidence of record does not indicate that the Veteran was treating for high blood pressure or hypertension either in-service or within several years of service. Furthermore, the February 2013 VA examiner did not find that the Veteran's hypertension was related to his service. Thus, the evidence of record which addresses the etiology of the Veteran's hypertension, did not link the Veteran's hypertension and his service. As such, service-connection for hypertension is not warranted. The Board finds the February 2013 VA examiner's medical opinion highly probative to the issue of whether the Veteran's hypertension is related to service. The examiner possesses the necessary education, training, and expertise to provide the requested opinion. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The opinion was based on a review of the claims file and an interview of the Veteran. The examiner's review of the Veteran's claims file consists of his service treatment records and post-service medical evidence, and his contentions, upon which the examiner relied upon in giving the opinion. It is clear that the examiner took into consideration all relevant factors in giving the opinion. Significantly, the Veteran has not presented or identified any contrary medical opinion that supports the claim for service connection. VA adjudicators are not free to ignore or disregard the medical conclusions of a VA physician, and are not permitted to substitute their own judgment on a medical matter. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Willis v. Derwinski, 1 Vet. App. 66 (1991). The Board finds that the only medical opinion evidence of record showed that the Veteran's hypertension was not related to service. The Board has also considered the Veteran's lay statements, including his hearing testimony. The Board also notes that the Veteran indicated he began taking hypertension medication 30 years ago. However, there is no evidence or record which supports this statement. In fact, the evidence of record is in opposition to that statement, including the December 1988 and January 1989 VA medical records and the Veteran's statement in his February 2013 VA examination that he began taking hypertension medication over a decade after he separated from service. Although the Board recognizes that the Veteran is competent to describe observable symptoms of hypertension, including his high blood pressure readings, he is not competent to opine as to the etiology of his hypertension, as he has not been shown to possess the requisite training or credentials needed to render a competent opinion as to medical diagnosis or causation. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As such, the Veteran's lay opinions that his hypertension was related to his active service do not constitute competent medical evidence and lack probative value. In sum, the claims file does not contain competent and credible evidence that the Veteran's hypertension is related to service. Accordingly, as the preponderance of the evidence is against the claim for service connection, the benefit-of-the-doubt rule is not for application, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER New and material evidence having been submitted, the claim of entitlement to service connection for a hypertension is reopened. Entitlement to service connection for hypertension is denied. New and material evidence having been submitted, the claim of entitlement to service connection for a disability manifested by shortness of breath, also claimed as COPD, is reopened. REMAND Although further delay is regrettable, the Board finds that additional development is necessary prior to appellate review. The Veteran seeks an increased rating for his cervical spine disability and a compensable rating for his bilateral hearing loss. In his October 2017 hearing, the Veteran and his wife testified that these disabilities have increased in severity. The last VA examination regarding the Veteran's cervical spine or his bilateral hearing loss was in February 2013. Therefore, a more contemporaneous examination is warranted. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the Veteran with a thorough and contemporaneous medical examination) and Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (an examination too remote for rating purposes cannot be considered "contemporaneous"). Absent presentation by the Veteran of new and material evidence, VA has no duty to provide an examination in cases where the Veteran seeks to reopen a previously denied claim. 38 CR 3.159(c)(4)(C)(iii) (2017). However, once VA undertakes to provide an examination, even if not statutorily obligated to do so, VA must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In regards to the Veteran's request to reopen his claim for service connection for left wrist carpel tunnel syndrome, a February 2013 VA examination found that the Veteran did not have left wrist carpel tunnel syndrome. The examiner stated that the Veteran had in-service symptoms of left wrist carpel tunnel syndrome, but was not diagnosed with left wrist carpel tunnel syndrome. The Board notes, however, that such conclusion is contrary to an August 1987 STR wherein the Veteran was diagnosed with median nerve compression at the wrist bilaterally, an August 1987 STR wherein the Veteran was diagnosed with carpel tunnel syndrome bilaterally, and a September 1987 STR which indicated he had carpel tunnel syndrome in his left wrist which had been present for approximately the past 8 to 9 years. The February 2013 examiner, however, did not address these records. When an examination is inadequate, the Board must remand the case for further development. Bowling v. Principi, 15 Vet.App. 1 (2001), 38 C.F.R. § 4.2 (2017). Thus, the Board finds that a new VA examination that adequately addresses all the evidence of record, to include the STRs discussed above, is warranted. In regards to the Veteran's claim for entitlement to service connection for a disability manifested by shortness of breath, also claimed as COPD, the Board notes that in its Decision above, it reopened the Veteran's claim due to a June 2012 private medical record indicating that the Veteran had "mild or early" COPD. A February 2013 VA examination, however, did not address this diagnosis or the medical evidence associated with that diagnosis. Furthermore, the examination did not address the RO's concession of asbestos exposure, as documented in the October 2016 statement of the case. As such, the Board finds that the February 2013 VA examination was inadequate for adjudication purposes and a new VA examination is warranted. Accordingly, the case is REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Associate with the record any VA clinical documentation not already of record pertaining to treatment of the Veteran, including that provided after 2016. 2. Contact the Veteran and afford him the opportunity to identify by name, address, and dates of treatment or examination any relevant private medical treatment records for his cervical spine disability, bilateral hearing loss, left wrist carpel tunnel syndrome, or any respiratory disability. After securing the proper authorizations, obtain all the records of treatment or examination from all the sources listed by the Veteran that are not already on file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. Thereafter, schedule the Veteran for a VA examination to determine the nature and severity of his service-connected cervical spine disability. The claims file, including a copy of this Remand, must be made available to the examiner and the examiner should indicate in his/her report whether or not such was reviewed. All necessary tests and studies should be accomplished. The examination report must include a complete rationale for all opinions expressed. (a) The VA examiner should conduct range of motion testing of the Veteran's cervical spine, expressed in degrees in active motion, passive motion, weight-bearing, and nonweight-bearing. (b) The VA examiner should render specific findings as to whether, during the examination, there is objective evidence of pain on motion, weakness, excess fatigability, or incoordination associated with the cervical spine. If pain on motion is observed, the VA examiner should indicate the point at which pain begins. To the extent possible, the VA examiner should express any additional functional loss in terms of additional degrees of limited motion. (c) The examiner should also state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of his cervical spine symptoms and/or after repeated use over time. Based on the Veteran's lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. (d) The examiner should set forth any neurological findings associated with the Veteran's service connected cervical disc disorder. In doing so, the examiner should identify, and comment on the frequency, extent and severity of any neurological disability with respect to each extremity. All neurological manifestations should be described in detail. If appropriate, the examiner should identify each nerve that is impaired (i.e., upper radicular group, middle radicular group, lower radicular groups, all radicular groups, radial nerve, median nerve, ulnar nerve, musculocutaneous nerve, circumflex nerve, and/or long thoracic nerve) and the extent of that impairment (i.e., mild, moderate, severe, or complete). 4. Thereafter, schedule the Veteran for a VA examination to determine the nature and severity of his service-connected bilateral hearing loss. The claims file, including a copy of this Remand, must be made available to the examiner and the examiner should indicate in his/her report whether or not such was reviewed. All necessary tests and studies should be accomplished. The examination report must include a complete rationale for all opinions expressed. The examiner should also elicit from the Veteran information as to the effect his bilateral hearing loss has on his daily living. The examiner must explain the rationale for all opinions. 5. Thereafter, schedule the Veteran for a VA medical examination by a physician (M.D.) to determine the nature and etiology of any left wrist carpel tunnel syndrome. The claims file, including a copy of this Remand, must be made available to the examiner and the examiner should indicate in his/her report whether or not such was reviewed. All necessary tests and studies should be accomplished. The examiner should: (a.) Identify any diagnosed left wrist carpel tunnel syndrome; (b.) If there is a diagnosis of left wrist carpel tunnel syndrome, provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's left wrist carpel tunnel syndrome had onset in service or within one year following separation from service, or was causally related to service. In providing the above opinion, the examiner must address the STRs, as referenced above, noting that the Veteran was found to have left wrist carpal tunnel syndrome in service. The examiner must provide a complete rationale on which his/her opinion is based, and must include a discussion of the medical principles as applied to the medical evidence and facts used in establishing his or her opinion. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a conclusion as it is to find against it. If the examiner finds that he/she cannot provide an opinion without resorting to speculation, he/she should explain the inability to provide an opinion. 6. Thereafter, schedule the Veteran for a VA medical examination by a physician (M.D.) to determine the nature and etiology of any respiratory disability, including COPD. The claims file, including a copy of this Remand, must be made available to the examiner and the examiner should indicate in his/her report whether or not such was reviewed. All necessary tests and studies should be accomplished. The examiner should: (a.) Identify any diagnosed respiratory disability, including COPD; (b.) If there is a diagnosis of a respiratory disability, provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that such a disability had onset in service or within one year following separation from service, or was causally related to service, to include exposure to asbestos. The examiner must provide a complete rationale on which his/her opinion is based, and must include a discussion of the medical principles as applied to the medical evidence and facts used in establishing his or her opinion. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a conclusion as it is to find against it. If the examiner finds that he/she cannot provide an opinion without resorting to speculation, he/she should explain the inability to provide an opinion. 7. After ensuring compliance with the development requested above, readjudicate the claims. If any decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. The appellant 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. §§ 5109B, 7112 (2012). ______________________________________________ Lesley A. Rein Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs