Citation Nr: 18141504 Decision Date: 10/10/18 Archive Date: 10/10/18 DOCKET NO. 14-25 352A DATE: October 10, 2018 REMANDED Entitlement to service connection for Bell’s Palsy, claimed as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for left eye infection, claimed as secondary to Bell's Palsy, is remanded. Entitlement to service connection for an ear infection, claimed as secondary to Bell’s Palsy, is remanded. Entitlement to service connection for headaches, claimed as secondary to service-connected PTSD, is remanded. Entitlement to service connection for atypical chest pain, including as secondary to service-connected PTSD, is remanded. Entitlement to service connection for hemorrhoids is remanded. Entitlement to service connection for a skin disability is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1989 to August 1991. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California, which denied the claims on appeal. The Veteran disagreed with the denials and a statement of the case (SOC) was issued in June 2014. He perfected a timely appeal in July 2014. In June 2018, the Veteran presented sworn testimony during a videoconference hearing, which was chaired by the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran’s VA claims file. The July 2012 rating decision also denied the Veteran’s claim of entitlement to service connection for PTSD. He disagreed with the denial and perfected an appeal in July 2014. In a June 2018 rating decision, service connection was granted for PTSD and a 50 percent disability rating was assigned. To the Board’s knowledge, the Veteran has not disagreed with that decision; this matter has accordingly been resolved. See Grantham v. Brown, 114 F.3d 1136 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second notice of disagreement must thereafter be timely filed to initiate appellate review of “downstream” issues such as the compensation level assigned for the disability or the effective date of service connection). 1. Entitlement to service connection for Bell’s Palsy, claimed as secondary to service-connected PTSD, is remanded. 2. Entitlement to service connection for left eye infection, claimed as secondary to Bell's Palsy, is remanded. 3. Entitlement to service connection for an ear infection, claimed as secondary to Bell’s Palsy, is remanded. 4. Entitlement to service connection for headaches, claimed as secondary to service-connected PTSD, is remanded. 5. Entitlement to service connection for atypical chest pain, including as secondary to service-connected PTSD, is remanded. 6. Entitlement to service connection for hemorrhoids. 7. Entitlement to service connection for a skin disability. A review of the record indicates that the Veteran’s entire claims file was lost during the pendency of the appeal. A January 2017 memorandum from the Agency of Original Jurisdiction (AOJ) indicated that multiple unsuccessful searches for the claims file were conducted. The RO thereafter attempted to rebuild the Veteran’s claims file. The rebuilt file does not include the June 2014 SOC pertaining to the claims on appeal. In addition, the notification letter for the July 2012 rating decision indicates that the Veteran submitted private nexus opinions in support of his skin disability, headaches, Bell’s Palsy claims; these nexus opinions have not been recovered. Further, a review of the record before the Board reveals that the RO did not notify the Veteran of these missing records. As indicated above, a January 2017 AOJ memorandum addressed efforts to search for and rebuilt the claims file; however, there is no notice to the Veteran of the missing files. Under 38 C.F.R. § 3.159(e), the RO must provide the Veteran with notice that the records cannot be found. The notice must include identity of the records, an explanation of the efforts made to obtain the records, and a description of further action VA will take regarding the claim. The Veteran should also be afforded the opportunity to submit any copies of relevant records within his possession. 38 C.F.R. § 3.159(e)(1). There is no evidence in this case that the RO took appropriate steps to notify the Veteran and afford him the opportunity to submit copies of records in his possession. Accordingly, the Board finds that a remand is necessary for the RO to associate all pertinent procedural and medical records related to the claims at issue with the record before the Board. The Veteran must also be provided with notice of the missing records pursuant to 38 C.F.R. § 3.159(e)(1), and given the opportunity to submit copies of these records to the AOJ. Moreover, at the June 2018 Board hearing, the Veteran asserted that he suffers from Bell’s Palsy and headaches as secondary to his service-connected PTSD. As the Veteran is service-connected for PTSD (see, e.g., the rating decision dated June 2018) and has current diagnoses of Bell’s Palsy and headaches (see, e.g., VA treatment records dated May 2008 and October 2014), the Board finds that the Veteran should be afforded a VA medical opinion in order to obtain a nexus opinion to address the Veteran’s contentions of secondary service connection to include aggravation. The matters are REMANDED for the following action: 1. The AOJ should associate with the record before the Board all available procedural and evidentiary documents during the pendency of the Veteran’s claims addressed in the July 2012 rating decision, to include the missing private nexus opinions referenced above. The AOJ should also associate the missing June 2014 SOC and any other available documents related to the claims on appeal. If these records are deemed unavailable, the claims file should be annotated to reflect such. 2. The AOJ should notify the Veteran of the missing records related to his claims in accordance with 38 C.F.R. § 3.159(e), and offer him the opportunity to submit any records within his possession. 3. The AOJ shall refer the VA claims file to an examiner(s) with appropriate expertise. The examiner(s) is(are) requested to review the claims file in its entirety including all service treatment records, VA, and private treatment records. Then, the examiner(s) should respond to the following: (a) Is it at least as likely as not that the diagnosed Bell’s Palsy and headaches were incurred in the Veteran’s active duty service? (b) Is it at least as likely as not that the diagnosed Bell’s Palsy and headaches were caused by a service-connected disability, to specifically include PTSD? (c) Is it at least as likely as not that the Veteran’s diagnosed Bell’s Palsy and headaches are aggravated (made worse as shown by comparing the current disability to medical evidence created prior to any aggravation) by a service-connected disability, to specifically include PTSD? If the Veteran’s diagnosed Bell’s Palsy and/or headaches are aggravated by a service-connected disability, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. Should the examiner decide that a physical examination of the Veteran is required to address these questions, one should be scheduled. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. The examiner must provide a rationale for each opinion given. K. CONNER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. K. Buckley, Counsel