Citation Nr: 18142260 Decision Date: 10/15/18 Archive Date: 10/15/18 DOCKET NO. 16-08 847 DATE: October 15, 2018 ORDER 1. Entitlement to an initial disability rating in excess of 10 percent for tinnitus is denied. 2. Entitlement to an initial compensable disability rating for anaphylactic shock due to an acquired allergic reaction to penicillin is denied. 3. Entitlement to service connection for ischemic heart disease (IHD), to include as due to exposure to herbicide agents, is denied. 4. Entitlement to service connection for hypothyroidism, to include as secondary to IHD, is denied. 5. Entitlement to service connection for a heart attack is denied. 6. Entitlement to service connection for a transient ischemic attack (TIA) is denied. REMANDED 7. Entitlement to service connection for left ear hearing loss is remanded. 8. Entitlement to service connection for sleep apnea is remanded. 9. Entitlement to service connection for renal insufficiency is remanded. 10. Entitlement to service connection for aortic dissection is remanded. 11. The application to reopen a claim of entitlement to service connection for hypertension is remanded. FINDINGS OF FACT 1. The Veteran is in receipt of the maximum schedular disability rating for tinnitus. 2. Anaphylactic shock disability has not manifested with attacks without laryngeal involvement lasting one to seven days and occurring two to four times a year during the appeal period 3. The Veteran did not incur an event, injury, or disease related to IHD during active duty service, to include being exposed to herbicide agents, including Agent Orange, while stationed in South Korea during the Vietnam Era. 4. The Veteran did not incur an event, injury, or disease related to hypothyroidism during active duty service, and such a disorder is not caused or aggravated by a service-connected disability. 5. The Veteran did not incur an event, injury, or disease related to a heart attack disorder during active duty service, and this disorder did not manifest in service or within one year of separation from active duty service. 6. The Veteran did not incur an event, injury, or disease related to the TIA disorder during active duty service, and this disorder did not manifest in service or within one year of separation from active duty service. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial disability rating in excess of 10 percent for tinnitus have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.87, Diagnostic Code (DC) 6260 (2017). 2. The criteria for entitlement to an initial compensable disability rating for anaphylactic shock due to an acquired allergic reaction to penicillin have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.104, DC 7199-7118 (2017). 3. The criteria for entitlement to service connection for IHD, to include as due to exposure to herbicide agents, have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2017). 4. The criteria for entitlement to service connection for hypothyroidism, to include as secondary to IHD, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310 (2017). 5. The criteria for entitlement to service connection for a heart attack have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 6. The criteria for entitlement to service connection for a TIA have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from August 1964 to May 1971. In September 2016, the Veteran filed a notice of disagreement (NOD) with the Agency of Original Jurisdiction’s (AOJ’s) February 2016 decision disagreeing with the amount of benefits awarded for the Veteran’s medical expenses in 2015. As the record indicates that the AOJ is diligently developing this claim, and the matter has not been certified for appellate review, the Board will not undertake review of this matter at this time. VA’s duty to assist includes providing a medical examination and/or obtaining a medical opinion when necessary to make a decision on a claim, as defined by law. See 38 U.S.C. § 5103A (2012); 38 C.F.R. §§ 3.159(c)(4), 3.326(a) (2017); see also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Veteran has not been provided with VA examinations for his service connection claims for IHD, hypothyroidism, a heart attack, and a TIA. However, as explained below, the Board finds that there was no event, injury, or disease related to the Veteran’s current IHD, hypothyroidism, a heart attack, and a TIA that occurred in service, which is one of the criteria needed for entitlement to a VA examination. McLendon, 20 Vet. App. at 81; see 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). VA, therefore, has no duty to provide medical examinations for these claims. The Board notes that on many occasions the Veteran has requested various records from VA, as well as the Department of Defense. VA’s duty to assist also includes making reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate a claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating a claim. See Golz v. Shinseki, 590 F.3d 1317, 1320-21 (2010). The Board finds that VA has satisfied its duty to assist by acquiring service treatment and personnel records, and records of VA and private treatment. Increased Ratings, Generally The Veteran contends that the disability ratings for tinnitus and anaphylactic shock due to an acquired allegoric reaction to penicillin disabilities should be rated higher than the currently-assigned disability ratings. VA has adopted a Schedule for Rating Disabilities (Schedule) to evaluate service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R., Part IV. Disability evaluations assess the ability of the body as a whole, the psyche, or a body system or organ to function under the ordinary conditions of daily life, to include employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. Id. In disability rating cases, VA assesses the level of disability from the initial grant of service connection or a year prior to the date of application for an increased rating and determines whether the level of disability warrants the assignment of different disability ratings at different times over the course of the claim, a practice known as “staged ratings.” The Veteran appealed the initially-assigned disability ratings for the tinnitus and the anaphylactic shock disabilities, and thus, the appeal period for these disabilities stems from April 28, 2011. When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a) (2012). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). 1. Tinnitus The Veteran contends that his tinnitus disability should be rated higher than the currently-assigned 10 percent rating. Tinnitus is rated under 38 C.F.R. § 4.87, DC 6260, which provides a maximum 10 percent evaluation for recurrent tinnitus. Note (2) states that a single evaluation for recurrent tinnitus is to be assigned, whether tinnitus is present in one or both ears. A higher evaluation for tinnitus is not available in the Schedule. The Veteran filed a service connection claim for tinnitus in April 2011. The Veteran underwent a VA examination in August 2012, during which he reported that his tinnitus onset two to three days after he attended a live fire exercise at Fort Benning, Georgia in late 1969. He stated that he experienced temporary threshold shifts and tinnitus at that time. The examiner determined that the Veteran had intermittent, recurrent tinnitus in the left ear. The Veteran stated that his intermittent tinnitus was distracting and that it caused a lack of focus with tasks or in social settings. In his September 2012 NOD and February 2016 substantive appeal to the Board (VA Form 9), the Veteran disagreed with the assigned 10 percent disability rating assigned for tinnitus disability in very general terms. A review of the Veteran’s VA treatment records since September 2011 does not show that he complained of tinnitus symptoms during the appeal. The Board has reviewed the evidence of record and finds that a disability rating in excess of 10 percent for tinnitus is not warranted during the appeal. Specifically, the Veteran is already in receipt of the maximum schedular disability rating for this disability. As there is no legal basis upon which to award a higher schedular evaluation for tinnitus, or separate schedular evaluations for tinnitus in each ear, the Veteran’s appeal is denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994); see also 38 C.F.R. § 4.87, DC 6260. Accordingly, as the preponderance of the evidence is against the Veteran’s claim, the benefit of the doubt doctrine does not apply, and the claim is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 4.3. 2. Anaphylactic Shock Due to an Acquired Allergic Reaction to Penicillin The Veteran also contends that anaphylactic shock due to an acquired allergic reaction to penicillin should be rated compensable. The Veteran’s disability is rated under 38 C.F.R. § 4.104, DC 7118, which rates symptoms of angioneurotic edema. A 10 percent rating is warranted for attacks without laryngeal involvement lasting one to seven days and occurring two to four times a year. A 20 percent rating is warranted for attacks without laryngeal involvement lasting one to seven days and occurring five to eight times a year, or; attacks with laryngeal involvement of any duration occurring once or twice a year. A maximum schedular rating of 40 percent is warranted for attacks without laryngeal involvement lasting one to seven days or longer and occurring more than eight times a year, or; attacks with laryngeal involvement of any duration occurring more than twice a year. The Veteran filed a claim for service connection for this disability in April 2011. In a September 2012 rating decision, the AOJ granted service connection for this disability because the evidence, including the Veteran’s service treatment records, showed that he had an allergic reaction to penicillin while in service. The AOJ assigned a noncompensable (zero percent) disability rating because the evidence did not show that he had any symptoms of this disability during the appeal period. In his September 2012 NOD and February 2016 VA Form 9, the Veteran stated that he has not had any anaphylactic shocks due to an acquired allergic reaction to penicillin since 1978, but he indicated he lived with the idea that a potential attack could end his life. Given this evidence, the Board finds that the anaphylactic shock disability has not manifested with attacks without laryngeal involvement lasting one to seven days and occurring two to four times a year during the appeal. A thorough review of the evidence of record, including the Veteran’s VA and private treatment records since April 2011, does not show that the Veteran complained of or was treated for any anaphylactic shock symptoms during the appeal period. In fact, the Veteran stated in his September 2012 NOD and February 2016 VA Form 9 that he has not had any anaphylactic shock symptoms since 1978, or approximately over 30 years prior to the current appeal period. These symptoms indicate that the Veteran’s disability does not warrant a compensable rating at any time during the appeal. See 38 C.F.R. §§ 4.104, DC 7199-7118. Accordingly, the evidence does not show that entitlement to an initial compensable disability rating for anaphylactic shock due to an acquired allergic reaction to penicillin is warranted. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the Veteran’s claim is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 4.3. Service Connection, Generally The Veteran contends that his current IHD, hypothyroidism, heart attack, and TIA disorders were caused by his active duty service and/or caused or aggravated by his service-connected disabilities. Specifically, the Veteran contends that he was exposed to herbicide agents while stationed in South Korea during the Vietnam Era, which caused his current IHD. Furthermore, he asserts that his hypothyroidism was caused or aggravated by his IHD. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). “To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Service connection may also be established under 38 C.F.R. § 3.303(b), if a chronic disease or injury is shown in service, and subsequent manifestations of the same chronic disease or injury at any later date, however remote, are shown, unless clearly attributable to intercurrent causes. Service connection may also be established under 38 C.F.R. § 3.303(b), where a disability in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. The continuity of symptomatology provision of 38 C.F.R. § 3.303(b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331, 1340 (Fed. Cir. 2013). Certain heart disorders, including arteriosclerosis, nephritis, and organic heart disease, are chronic diseases listed under 38 C.F.R. § 3.309(a); thus, 38 C.F.R. § 3.303(b) is applicable. Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases, such as certain heart disorders, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1110, 1112, 1113 (2012); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. However, where the evidence does not warrant presumptive service connection, a veteran is not precluded from establishing service connection with proof of direct causation. See Combee, 34 F.3d at 1043. Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). When service connection is established for a secondary disability, the secondary disability shall be considered a part of the original disability. Id. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (2017). 3. IHD The Veteran contends that his current IHD disability was caused by his exposure to herbicide agents while stationed in the United States and South Korea during the Vietnam Era. The record shows that the Veteran has current IHD. Specifically, numerous VA treatment records, including a November 2012 VA progress note, show that the Veteran was diagnosed with coronary artery disease (CAD) status-post coronary artery bypass grafting (CABG) and ischemic cardiomyopathy. Thus, the first element of service connection is met. Regarding the second and third elements of service connection, the Board notes that the Veteran’s service treatment records do not show any complaints of or treatment for IHD during active duty service. Specifically, his June 1964 enlistment and April 1971 separation reports of medical examination and history show that clinical evaluations of the heart and vascular system were normal. The Veteran specifically denied multiple symptoms, such as shortness of breath, pain or pressure in chest, palpitation or pounding heart, and high or low blood pressure, although he complained of various other disorders and symptoms. Overall, the record shows that the Veteran was first diagnosed with IHD in 2007. Nonetheless, the Veteran contends that his current IHD is caused by his active duty service because he was exposed to tactical herbicide agents in service. The Board notes that for the diseases listed in 38 C.F.R. § 3.309(e), including IHD, the evidentiary requirements for establishing entitlement to service connection benefits are more relaxed. The regulations provide that when exposure to herbicide agents is established during active duty, diseases associated with herbicide exposure that manifest at any date, however remote, after service are entitled to service connection, unless they are clearly attributable to causes unrelated to service (“intercurrent causes”). See 38 C.F.R. § 3.307(d). The diseases listed at 38 C.F.R. § 3.309(e) must become manifest to a degree of 10 percent or more at any time after service, except for certain diseases, which are required to have manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during the active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). Claimants who served between April 1, 1968, and August 31, 1971, in a unit that, as determined by the Department of Defense, operated in or near the Korean Demilitarized Zone (DMZ) in an area in which herbicides are known to have been applied during that period shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iv). The Veteran contends in various statements that he was exposed to herbicide agents at multiple locations during his active duty service, including in Maryland, Kentucky, and South Korea. Specifically, in multiple statements throughout the appeal, the Veteran, as well as a former service member, stated that the Veteran was exposed to Agent Orange at ASCOM Depot, in BuPyeong, South Korea between February 1968 and April 1969 because that was a waypoint for shipments of Agent Orange to the DMZ. Additionally, they asserted that they were exposed to Agent Orange while digging and searching for buried coins in soil on which herbicide agents were used. In support of these contentions, the Veteran also submitted letters, which he wrote during active duty service, showing that he searched for coins at the base where he was stationed in South Korea. Additionally, the Veteran asserted on many occasions that he was exposed to Agent Orange while located at the Aberdeen Proving Grounds and Fort Meade, Maryland, as well as at Fort Campbell, Kentucky, because tactical herbicide agents were stored or tested at these locations. The AOJ attempted to verify the Veteran’s claimed in-service exposure to herbicide agents, including Agent Orange, at the various locations and in the various circumstances that the Veteran alleged. In July 2010 and December 2015 personnel information exchange system (PIES) replies, and multiple emails, the Joint Services Records Research Center (JSRRC) and the National Personnel Records Center indicated that there were no records showing that the Veteran was exposed to herbicide agents, including Agent Orange, during his active duty service. Furthermore, the Department of Defense and these records repositories determined that the evidence does not support that the Veteran participated in testing or storage of tactical herbicide agents while in the United States, that herbicide agents were used at the ASCOM Depot in BuPyeong, South Korea during his station in that country, and that there was no evidence that the Veteran was located at the DMZ during his active duty service, which the Veteran does not contend. Given this evidence, the Board finds that the Veteran did not incur an event, injury, or disease related to IHD during active duty service, to include being exposed to herbicide agents, including Agent Orange, while stationed in the United States and South Korea during the Vietnam Era. As noted above, the Veteran’s service treatment records do not show any complaints or treatment for IHD, and the Veteran denied having any abnormal heart symptoms, including palpitations or a pounding heart, chest pain, shortness of breath, or high or low blood pressure, in his April 1971 service separation evaluation. The evidence of record shows that the Veteran was first diagnosed with IHD in 2007, or approximately over 35 years following separation from active duty service. Additionally, the Veteran’s various statements regarding his exposure to Agent Orange in South Korea, as well as in Kentucky and Maryland, are not substantiated by the evidence of record. Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable, and the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 4. Hypothyroidism The Veteran also contends that his current hypothyroidism should be service connected because it is caused or aggravated by his IHD. Initially, the Board notes that the Veteran has been diagnosed with this disorder during the appeal period. For example, a November 2012 VA progress note showed that he was diagnosed with hypothyroidism and that he was taking Synthroid medication. Thus, the first element of service connection is met. Regarding the second element of service connection, namely, an in-service incurrence or aggravation of a disease or injury, the Board notes that the Veteran’s service treatment records do not show any complaints of or treatment for hypothyroidism in service. Specifically, the Veteran’s June 1964 enlistment and April 1971 separation reports of medical examination and history show that clinical evaluation of the endocrine system was normal. Overall, the record shows that the Veteran was diagnosed with or treated for hypothyroidism in 2007. Additionally, the Veteran stated in his April 2011 claim for service connection for this disorder that he was diagnosed with hypothyroidism for the first time in December 2007, or approximately over 35 years following separation from active duty service. Given this evidence, the Board finds that the Veteran did not incur an event, injury, or disease related to his current hypothyroidism during active duty service. In fact, the Veteran does not contend that his current hypothyroidism is caused by any incident of his active duty service. Rather, he contends that this disorder is caused or aggravated by his IHD disorder. However, as noted above, the preponderance of the evidence is against a finding of service connection for IHD. Additionally, while the Veteran’s tinnitus and anaphylactic shock due to an acquired allergic reaction to penicillin were granted service connection, neither the Veteran nor the record contend that his current hypothyroidism is caused or aggravated by these service-connected disabilities. Thus, service connection on a secondary basis cannot be granted for the Veteran’s current hypothyroidism as this disability is not caused or aggravated by a service-connected disability. See 38 C.F.R. § 3.310. Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable, and the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 5. & 6. Heart Attack and TIA The Veteran contends that his heart attack and TIA disorders were caused by his active duty service. Because the evidence pertaining to these disorders is located in the same or similar records, the Board shall analyze these matters together below. Initially, the Board notes that the Veteran has current diagnoses associated with residuals of a heart attack and TIA during the appeal. Specifically, the record, including VA and private treatment records, shows that the Veteran had a heart attack in August 2007, and that he had a TIA in July 2007. Thus, the first element of service connection for each disorder is met. However, the Board finds that the Veteran did not incur an event, injury, or disease related to his current heart attack and TIA disorders during active duty service, and that these disorders did not manifest in service or within one year of separation from active duty service. Specifically, his service treatment records, including his June 1964 service enlistment evaluation and April 1971 service separation evaluation, are silent for any treatment of or complaints for these disorders during his active duty service. As noted above, clinical evaluations of the heart and vascular system at separation were both normal. The record shows that the Veteran was first diagnosed with a heart attack in August 2007 and a TIA in July 2007, or approximately over 35 years after separation from active duty service. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Since that time, the Veteran’s VA and private treatment records show that he has a history of a TIA and heart attack, as well as CAD status-post CABG. However, these VA and private treatment records do not discuss the causal relationship between the current residuals of a heart attack and a TIA and the Veteran’s active duty service. Furthermore, apart from filing and appealing the present claim, and noting on several occasions, including in the September 2012 NOD, that his hypothyroidism, heart attack, and TIA disorders are interconnected, the Veteran has not submitted any lay or medical evidence showing these disorders began in service or within one year or separation from active duty service. Overall, the preponderance of the evidence is against a finding that the Veteran incurred an event, injury, or disease related to his current heart attack and TIA disorders during active duty service, and that these disorders did manifested in service or within one year of separation from active duty service. Thus, the second element of service connection is not met. Accordingly, as the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not applicable, and the claims are denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND The Board must remand the Veteran’s claims for service connection for left ear hearing loss, sleep apnea, renal insufficiency, and aortic dissection, as well as the application to reopen entitlement to service connection for hypertension, for additional evidentiary and procedural development. The Board must remand the claim for entitlement to service connection for left ear hearing loss to afford the Veteran a new VA examination to determine the cause and nature of this disorder. Specifically, the Veteran underwent a VA examination for his hearing loss claim in August 2012, during which the Veteran was diagnosed with left ear hearing loss. The VA examiner noted that she reviewed 21 pages of the Veteran’s records prior to determining that she could not provide a medical opinion regarding the cause of the Veteran’s hearing loss without resorting to speculation. The Board finds this medical opinion to be inadequate to adjudicate the Veteran’s left ear hearing loss claim because this medical opinion did not answer whether the Veteran’s left ear hearing loss was caused or otherwise related to his active duty service. Furthermore, this medical opinion is inadequate because although the examiner noted that she reviewed 21 pages of the Veteran’s records, the Veteran’s claims file contains many more of pages of records and documents pertinent to the Veteran’s claim. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Thus, on remand, the AOJ should schedule the Veteran for a new VA examination to determine the cause and nature of his left ear hearing loss disorder. The Board must remand the Veteran’s claims for entitlement to service connection for sleep apnea, renal insufficiency, and aortic dissection, as well as the application to reopen entitlement to service connection for hypertension, for additional procedural development. Specifically, the AOJ denied these claims in an August 2017 rating decision. While the Veteran listed 132 issues he disagreed with in his October 2017 NOD (VA Form 21-0958), in essence, he disagreed with the AOJ’s denials of service connection for sleep apnea, renal insufficiency, and aortic dissection, as well as the denial of the claim to reopen entitlement to service connection for hypertension, but for approximately 132 reasons. In an October 2017 letter, the AOJ requested that the Veteran further explain which matters he was appealing from the August 2017 rating decision. In a December 2017 statement, the Veteran further explained in a statement in support of his claims why he filed an NOD with the four issues denied in the August 2017 rating decision. However, in a December 2017 letter, the AOJ informed the Veteran that it could not consider the Veteran’s December 2017 statement as a valid NOD because he did not submit this statement on the proper form, i.e., on a VA Form 21-0958. In a subsequent December 2017 statement, the Veteran reiterated his contentions and resubmitted the October 2017 VA Form 21-0958. To date, the AOJ has not issued a statement of the case (SOC) addressing the claims of entitlement to service connection for sleep apnea, renal insufficiency, and aortic dissection, as well as the application to reopen service connection for hypertension. See Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, these matters are remanded for the AOJ to rectify this procedural deficiency. The matters are REMANDED for the following actions: 1. Schedule the Veteran for an appropriate VA audiological examination to assist in determining the nature and cause of his current left ear hearing loss disorder symptoms. All appropriate tests, studies, and consultations should be accomplished and all clinical findings should be reported in detail. Based upon a review of the relevant evidence, history provided by the Veteran, and sound medical principles, the VA examiner should provide an opinion as to: (a.) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s current left ear hearing loss manifested in service or within one year of separation from active duty service, and/or is caused by or otherwise related to his period of active duty service from August 1964 to May 1971. The examiner is asked to provide a rationale with reference to relevant evidence of record and/or medical principles, as appropriate, for all conclusions reached. If the examiner is unable to provide an opinion without resorting 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. 2. Issue an SOC addressing the claims of entitlement to service connection for sleep apnea, renal insufficiency, and aortic dissection, and the application to reopen a claim of entitlement to service connection for hypertension. Only if the Veteran perfects an appeal by submitting a timely VA Form 9, appeal to the Board, should the issues be returned to the Board for further appellate consideration. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Hodzic, Counsel