Citation Nr: 18142854 Decision Date: 10/17/18 Archive Date: 10/16/18 DOCKET NO. 16-04 858 DATE: October 17, 2018 ORDER Entitlement to service connection for tinnitus is denied. Entitlement to an evaluation higher than 50 percent for service-connected posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for a cervical spine disorder is remanded. Entitlement to service connection for coronary artery disease, to include as secondary to service-connected PTSD, is remanded. Entitlement to service connection for radiculopathy of the right upper extremity, to include as secondary to cervical spine degenerative disc disease, is remanded. Entitlement to service connection for radiculopathy of the left upper extremity, to include as secondary to cervical spine degenerative disc disease, is remanded. FINDINGS OF FACT 1. The more probative evidence of record demonstrates that the Veteran’s tinnitus is not etiologically related to his period of active duty service. 2. Throughout the appeal, the Veteran’s PTSD symptoms have caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for tinnitus have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2018). 2. The criteria for entitlement to an evaluation higher than 50 percent for service-connected PTSD have not been met. 38 U.S.C. § 1155, 5103, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.130, Diagnostic Code (DC) 9411 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty in the U.S. Marine Corps from January 2002 until January 2006, with subsequent Reserve service. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a June 2013 and May 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. On his May 2011 claim, the Veteran wrote that he sought service connection for C5 cervical radiculopathy, but in a May 2011 statement he wrote he was seeking service connection for cervical radiculopathy of C5-6 with herniated nucleus pulposus. The rating decision and statement of the case denied entitlement to service connection for cervical radiculopathy due to cervical spine condition. In the analysis, the RO addressed the merits of service connection for a cervical spine degenerative disc disease and radiculopathy. For ease of adjudication, the issues have been recharacterized as entitlement to a cervical spine disorder, and entitlement to service connection for cervical radiculopathy of the upper extremities due to a cervical spine disorder. Duties to Notify and Assist In the July 2014 notice of disagreement, the Veteran’s attorney submitted argument that appears to indicate that the March 2014 VA examination was inadequate. The attorney did not specifically identify any inadequacy in the examination report, and instead generally summarized the relevant law surrounding VA’s duty to obtain an adequate VA examination. Addressing those concerns, however, the Board finds the 2014 examination to be adequate. The 2014 examiner conducted a thorough diagnostic interview of the Veteran and addressed his current symptoms. The examination report also includes all information necessary to decide the claim. The Veteran has denied other mental health treatment, and there are no other relevant mental health records for the period being considered on appeal. Accordingly, although the examiner did not have the claims file to review, there are no relevant records regarding the PTSD issue. Also, the Veteran has not testified nor does the record reflect that his PTSD has worsened since he was last examined. Thus, the Board concludes that the March 2014 VA examination report is adequate to decide the claim. Neither the Veteran nor his attorney has raised any other issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). 1. Entitlement to service connection for tinnitus The Veteran seeks entitlement to service connection for tinnitus. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2017). 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 - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2017). In addition, service connection for certain chronic diseases, including tinnitus, may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a) (2018); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although the disease need not be diagnosed within the presumptive 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. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Additionally, for certain chronic diseases with potential onset during service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309 (2018); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran asserts that his current tinnitus symptoms are due to in-service exposure to hazardous noise. See July 2013 notice of disagreement. The Veteran is competent to self-diagnose tinnitus, and he was exposed to hazardous noise in service. See Charles v. Principi, 16 Vet. App. 370 (2014) (due to the inherently subjective nature of tinnitus, it is readily capable of lay diagnosis); see February 2002 service treatment record (STR) (showing the Veteran had a high likelihood of hazardous noise exposure). The issue remaining before the Board is whether the Veteran’s currently diagnosed tinnitus is etiologically related to his in-service noise exposure. The most probative evidence of record demonstrates that the diagnosed tinnitus is not due to the in-service noise exposure. The Veteran underwent a July 2015 VA audiology evaluation. At that time the Veteran reported occasional tinnitus that he estimated had been occurring for the prior 2 years, although he could not recall a specific incident or date related to its onset. The tinnitus occurred an average of once per week, and lasted between 2 and 10 minutes at a time. Audiological evaluation showed the Veteran’s hearing was normal bilaterally, and the Veteran reported symptoms of tinnitus. The examiner opined that the tinnitus was not due to the Veteran’s period of service, to include any in-service exposure to hazardous noise, explaining that tinnitus was not a symptom associated with hearing loss because the Veteran’s hearing was normal on examination, and the tinnitus did not develop until 7 years after separation from service. Rather, the examiner explained that the Veteran’s reported tinnitus pattern was consistent with the normal experience of most people who did not have hearing loss. Normal tinnitus experienced by most people without hearing loss lasted less than 5 minutes once a week, which was grossly consistent with the Veteran’s reported tinnitus pattern. The July 2015 examination report and opinion are highly probative as the examiner reviewed the Veteran’s relevant medical history, elicited relevant testimony, and provided a thorough rationale for the opinion. Although the Veteran has asserted that his tinnitus is due to in-service noise exposure, as a lay person he is competent to report to factual matters which he can observe, but not as to matters that require medical expertise, such as the relationships between noise exposure and internal audiological residuals thereof. See Layno v. Brown, 6 Vet. App. 465, 469 (1994); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The probative medical evidence of record weighs against a finding that the tinnitus is due to the Veteran’s period of service, and service-connection on a direct basis cannot be granted. Also, service connection is not warranted on a presumptive basis because the record fails to demonstrate tinnitus first began in service and persisted thereafter. The Veteran first filed his claim for service connection for tinnitus in May 2011, and reported that tinnitus had its onset in 2003, during service. This statement, however, is inconsistent with other testimony of record and is contradicted by the STRs. On November 2003, October 2004, and November 2005 post deployment questionnaires, the Veteran specifically denied having any ringing of the ears. Additionally, at the 2015 examination he reported that he first began to notice tinnitus symptoms around 2013, which is 7 years after separation from active duty and 4 years after leaving the Reserves. To the extent the May 2011 claim for benefits indicates that tinnitus began in 2003, the Board does not find that testimony to be credible as it is inconsistent with the available records from that time and inconsistent with the Veteran’s later testimony. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff’d, 78 F.3d 604 (Fed. Cir. 1996). Even if the Board assumes the Veteran’s tinnitus was present in May 2011 when he first filed his claim, that was several years after separation from service. Continuity of tinnitus symptoms from service has not been established, nor is there evidence indicating that tinnitus developed within one year of separation from service. Thus, entitlement to service connection for tinnitus on a presumptive basis is not warranted. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to an evaluation higher than 50 percent for service-connected PTSD Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2018). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2018). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2018). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3 (2018). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2018). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating an increased rating claim, the relevant time period for consideration is the time period one year before the claim was filed. Hart, 21 Vet. App. at 509. The Veteran’s service-connected PTSD is rated under 38 C.F.R. § 4.130, DC 9411 (2018). That DC uses the General Rating Formula for Mental Disorders, which provides for a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing effective work and social relationships. Id. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for a mental disorder when there is total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation or own name. Id. Global Assessment of Functioning (GAF) scale scores are based on a scale indicating the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Carpenter v. Brown, 8 Vet. App. 240 (1995); Richard v. Brown, 9 Vet. App. 266 (1996); American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders, 4th Ed. (1994) (DSM-IV). Effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by removing outdated references to the DSM-IV. The amendments replace those references with references to the recently updated DSM-5. The Veteran’s claim was certified to the Board in 2017. One distinction from DSM-IV is, according to the DSM-5, clinicians do not typically assess Global Assessment of Functioning (GAF) scores. The DSM-5 introduction states that it was recommended that the GAF be dropped from DSM-5 for several reasons, including its conceptual lack of clarity (i.e., including symptoms, suicide risk, and disabilities in its descriptors) and questionable psychometrics in routine practice. In this Veteran’s case, no GAF scores are available for consideration. The specified factors for each rating for mental disorders are examples, rather than requirements, for that particular rating. The Board will not limit its analysis solely to whether a veteran exhibited the symptoms listed in the rating criteria. The Board will instead focus on the level of occupation and social impairment caused by the symptoms. Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, “[w]ithout those examples, differentiating a 30% evaluation from a 50% evaluation would be extremely ambiguous.” Mauerhan, 16 Vet. App. at 442. The list of examples “provides guidance as to the severity of symptoms contemplated for each rating.” Mauerhan, 16 Vet. App. at 442. Each particular rating “requires sufficient symptoms of the kind listed in the [] requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation.” Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). A June 2013 rating decision granted entitlement to service connection for PTSD and assigned an initial 50 percent evaluation from May 20, 2011 onward. The Veteran did not appeal the initial rating assigned in that decision. Rather, the Veteran filed a claim for coronary artery disease secondary to service-connected PTSD in June 2013, which the AOJ adjudicated as a claim for an increased rating for PTSD. The 50 percent evaluation was then continued in an April 2014 rating decision with May 2014 notification letter that is the subject of the present appeal. In July 2014, VA received the Veteran’s notice of disagreement with the May 2014 notification letter. While the Board has reviewed all medical evidence in the claims file, the analysis will focus on the severity of the service-connected PTSD following the June 2013 final rating decision. The Veteran underwent a PTSD examination in March 2014. At that time, the Veteran reported that he had been married 3 years and had good relationships with his wife and children. He also had regular contact with his mother and brother, but not his father. He had infrequent contact with friends. The Veteran worked full time as a computer programmer, and reported no occupational difficulties. The Veteran denied participating in any psychotherapy, he was not taking any psychotropic medications, and he had no prior mental health hospitalizations. The Veteran reported writing software for a catastrophic insurance company. He also does some freelancing. He stated that he did not have any problems doing his jobs, but finds it stress with managing his time between work and family, and that he sometimes felt isolated at work due to a “clique” environment. Upon mental status examination, the Veteran was observed to be well-groomed and cooperative. His speech was fluent with an appropriate affect, and his thoughts were coherent and logical. He denied suicidal or homicidal ideations, and did not report any symptoms consistent with hallucinations nor delusions. The examiner identified symptoms of anxiety, chronic sleep impairment, disturbances of motivation and mood. The examiner noted the Veteran was dressed in business casual attire and was well-groomed. The Veteran was cooperative with fluent speech, a euthymic mood with a congruent affect. The Veteran’s thoughts were coherent and logical and he denied suicidal and homicidal ideations. The Veteran did not report any symptoms consistent with hallucinations or delusions. The examiner indicated the Veteran should engage in mental health care to address anxiety, hypervigilance, and feelings of isolation. Overall, the examiner indicated that the Veteran’s PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The evidence of record shows the Veteran’s PTSD does not warrant an evaluation higher than 50 percent at any point on appeal. Initially, the Board notes that there is not an inability to establish and maintain effective relationships. Although he reported infrequent contact with friends, no regular contact with his father, and difficulty at work, he was married with good relationships with his wife and children and had regular contact with his mother and brother. Additionally, although the examiner found there was deficiency in motivation and mood, the examiner did not find deficiencies in judgment or thinking. The examiner also noted that the Veteran denied suicidal ideations and was well-groomed. There was no evidence of obsessional rituals or impaired impulse control. Moreover, the Veteran’s speech was fluent and his thoughts were coherent and logical. Overall, the available medical evidence for the relevant period on appeal shows that the Veteran’s PTSD symptoms at worst are consistent with the 50 percent rating criteria, but no higher. 38 C.F.R. § 4.130 DC 9411. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for a cervical spine disorder. This issue is remanded to obtain a medical opinion. Generally, when VA undertakes to obtain an examination or opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In May 2013 the Veteran was afforded a VA neck conditions examination, and the examiner documented diagnoses of cervical spondylosis and disc herniation at C5-6 from April 2011. The examiner noted that an October 2002 STR documented the Veteran had complaints of pain in the lower neck and upper left side of the back pain for 1.5 years, but the examiner did not provide an opinion as to whether the Veteran’s currently diagnosed cervical spine disorders were etiologically related to his period of service. Accordingly, remand is required to obtain a nexus opinion. 2. Entitlement to service connection for coronary artery disease, to include as secondary to PTSD. First, this issue is also remanded to obtain an adequate medical opinion. Generally, when VA undertakes to obtain an examination or opinion, it must ensure that the examination or opinion is adequate. Barr, 21 Vet. App. at 312. A medical opinion should address the appropriate theories of entitlement. Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). A medical opinion that a disorder is not the result of an already service-connected disability does not address the issue of aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). The central issue in determining probative value of a medical opinion is whether the examiner was informed of the relevant facts. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). The Veteran was afforded a VA heart disease examination in July 2015, but the opinion provided in the report is inadequate. The examiner noted that coronary artery disease was diagnosed in April 2008, although the Veteran reported symptoms of chest pain for several years prior to 2008. The examiner opined that coronary artery disease was due to a blockage and was not caused by PTSD. Rather, blockages were likely secondary to “elevated cholesterol, poor diet, coronary artery disease, and more,” but not due to PTSD. The examiner then stated that while PTSD was not a direct cause of coronary artery disease, “smoking secondary to PTSD” could cause coronary artery disease. In this regard, the Veteran has also been diagnosed with tobacco use disorder, and the Board finds clarification is necessary as to whether the Veteran’s tobacco use is associated with his PTSD. Additionally, the 2015 examiner failed to address several medical articles submitted by the Veteran in July 2013 that generally stand for the proposition that PTSD is associated with a greater likelihood of cardiovascular morbidity. Also, the examiner only addressed secondary service connection causation and not aggravation, did not address whether coronary artery disease had its onset in service or within one year of separation from service, and did not address whether coronary artery disease was otherwise related to the Veteran’s period of active service. For these reasons, remand is required to obtain another VA opinion. Second, remand is required to obtain outstanding federal records. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c) (2017). This includes making as many requests as are necessary to obtain relevant records from a Federal department or agency, including, but not limited to, military records. 38 C.F.R. § 3.159(c)(2). In May 2011, VA obtained a copy of November 2007 notification of pending mobilization orders from the U.S. Marine Corps Mobilization Command and a September 2007 notice that the Veteran was ordered to active duty training for a mobilization screening. These records indicate there may be additional, unverified periods of active duty for training (ACDUTRA) and corresponding treatment records. Remand is required to verify all periods of ACDUTRA and inactive duty for training (INACDUTRA), and to attempt to obtain any outstanding STRs from those periods Third, remand is required to obtain VA and private treatment records. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c) (2017). This includes making as many requests as are necessary to obtain relevant records from a Federal department or agency, including, but not limited to, VA medical records. 38 C.F.R. § 3.159(c)(2). This also includes making reasonable efforts to obtain relevant private medical records. 38 C.F.R. § 3.159(c)(1). VA treatment records from June 2011 cite to an April 2006 electrocardiogram that showed a normal sinus rhythm with a T-wave abnormality, however the original record does not appear to be available for review and it is unclear whether the April 2006 record is a private treatment record or a VA treatment record. Also, a June 2007 VA treatment record notes the Veteran was treated at St. Josephs in April 2007 for atypical chest pain, and those records are also not available for review. On remand, VA should undertake necessary efforts to obtain the outstanding VA and private treatment records relevant to the claim of entitlement to service-connection for coronary artery disease. 3. – 4. Entitlement to service connection for radiculopathy of the right and left upper extremities, to include as secondary to cervical spine degenerative disc disease. The issues of entitlement to service connection for cervical radiculopathy are inextricably intertwined with the claim of entitlement to service-connection for a cervical spine disorder. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to remand the claim on appeal pending the adjudication of the inextricably intertwined claim. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. Contact the National Personnel Records Center, the Records Management Center, the Veteran’s unit(s), or any other appropriate entity to verify the dates of the Veteran’s periods of ACDUTRA and INACDUTRA from January 2006 through December 2009. The AOJ must identify each verified period of ACDUTRA and INACDUTRA in a memorandum to the file that should then be associated with the claims folder for the examiners review. Summarize the findings and all actions taken, and include a copy of the summary in the claims file. 2. Contact the National Personnel Records Center, the Records Management Center, the Veteran’s unit(s), or any other appropriate entity to obtain all STRs from January 2006 through December 2009. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 3. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment, to include a potentially outstanding April 2006 electrocardiogram report. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 4. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Specifically, request that the Veteran provide the necessary information for St. Josephs, and the facility at which the April 2006 electrocardiogram was performed. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the 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. 5. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of the claimed cervical spine disorder from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. (a.) For each diagnosed cervical spine disorder and all neurologic manifestations of a cervical spine disorder, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the each disorder had onset in, or is otherwise related to, active military service. (b.) Is it at least as likely as not (50 percent or greater probability) that the cervical spine degenerative disc disease manifested within one year of separation from service? (c.) The examiner must specifically address the Veteran’s assertions of an in-service injury to his upper back and shoulders, and the STRs showing October 2002 treatment for a levator scapulae strain. 6. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of the claimed coronary artery disease from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. (a.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that coronary artery disease had onset in, or is otherwise related to, active service or ACDUTRA. (b.) Is it at least as likely as not that a myocardial infarction occurred during a period of INACDUTRA? (c.) Is it at least as likely as not (50 percent or greater probability) that coronary artery disease manifested within one year of separation from service? (d.) Is it at least as likely as not (50 percent or greater probability) that coronary artery disease is caused or aggravated by service-connected PTSD, to include consideration of whether tobacco abuse is due to PTSD? (e.) The examiner must specifically address the following: 1) the Veteran’s testimony that he experienced chest pains several years prior to being diagnosed with coronary artery disease in 2008; 2) the reported April 2006 electrocardiogram showing a T-wave abnormality; 3) VA treatment records noting atypical chest pain in April 2007; 4) the articles submitted in July 2013 documenting a relationship between PTSD and increased cardiovascular morbidity; and 5) the July 2015 VA examiner’s findings that smoking could be a symptom of PTSD and a cause of the Veteran’s coronary artery disease. 7. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim, and that the consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2017). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Smith, Associate Counsel