Citation Nr: 18153177 Decision Date: 11/27/18 Archive Date: 11/27/18 DOCKET NO. 15-14 259A DATE: November 27, 2018 ORDER Entitlement to service connection for hypertriglyceridemia is denied. Entitlement to an effective date prior to April 26, 2011, for the award of service connection for PTSD is denied. Entitlement to an effective date prior to April 26, 2011, for the award of service connection for tinnitus is denied. REMANDED Entitlement to an evaluation in excess of 70 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. Entitlement to service connection for residuals of a right tibia fracture is remanded. Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for liver disease is remanded. Entitlement to service connection for headaches is remanded. Entitlement to an initial evaluation in excess of 10 percent for irritable bowel syndrome (IBS) is remanded. Entitlement to an effective date prior to April 26, 2011, for the award of service connection for IBS is remanded. FINDINGS OF FACT 1. Hypertriglyceridemia, by itself, does not constitute a disability for VA compensation purposes. 2. On April 26, 2011 the Veteran filed a claim for service connection for PTSD; there was no communication received prior to that date indicating an intent to file a claim. 3. On April 26, 2011 the Veteran filed a claim for service connection for tinnitus; there was no communication received prior to that date indicating an intent to file a claim. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertriglyceridemia have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 2. The criteria for entitlement to an effective date prior to April 26, 2011, for the award of service connection for PTSD have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (prior to March 24, 2015). 3. The criteria for entitlement to an effective date prior to April 26, 2011, for the award of service connection for tinnitus have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400 (prior to March 24, 2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from January 2003 to March 2004, with prior Reserve service. These matters come before the Board of Veteran’s Appeals (Board) on appeal from August 2012 and January 2013 rating decisions by the Regional Office (RO). Regarding the IBS initial rating and earlier effective date matters, as explained in detail below, these matters are remanded herein for the issuance of a Statement of the Case (SOC). See Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). At the Board hearing, the Veteran’s representative indicated that the Veteran had wished to appeal the January 2013 rating decision with regard to the denial of service connection for a hernia disability. Unfortunately, however, the Veteran’s February 2013 notice of disagreement did not include the hernia claim. Therefore, as no notice of disagreement was filed within one year of the January 2013 rating decision as to the hernia claim, that denial became final. See 38 U.S.C. § 7105 (2012). If the Veteran wishes to file a request to reopen the claim, the Board notes that effective March 24, 2015, VA amended its regulations requiring that a claim for VA compensation be provided on a form prescribed by the Secretary. See 38 C.F.R. §§ 3.1(p) and 3.150(a) (2015). Therefore, should the Veteran wish to file a request to reopen the claim for service connection for a hernia disability, he should do so on the required form which is available online at https://www.ebenefits.va.gov/ebenefits/ and at the local RO. Analysis 1. Entitlement to service connection for hypertriglyceridemia The Veteran claims that he has hypertriglyceridemia due to eating a high-fat diet in service (MREs). The Board acknowledges that the Veteran’s post-service VA treatment records show that hypertriglyceridemia was diagnosed in July 2009. See Records, received May 2011 at p.1 of 9. However, hypertriglyceridemia does not constitute a disability for VA compensation purposes – there is no diagnostic code providing for compensation for hypertriglyceridemia. Rather, it constitutes a medical finding of excessive triglycerides in the blood. See Dorland’s Medical Dictionary (30th Ed.) at p.890. The Court of Appeals for Veterans Claims has noted the same. The threshold requirement for service connection to be granted is competent evidence of the current existence of a disability. See Degmetich v. Brown, 104 F.3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992). Therefore, without a current disability for VA compensation purposes, the claim for service connection for hypertriglyceridemia must be denied. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not for application. 2. Entitlement to an effective date prior to April 26, 2011, for the award of service connection for PTSD An August 2012 rating decision awarded service connection for PTSD, effective April 26, 2011. The Veteran seeks entitlement to an earlier effective date for service connection. On April 26, 2011 (stamped-received date), the Veteran filed a formal claim (Form 21-526) for service connection for PTSD. There is no communication in the claims file prior to this April 2011 correspondence indicating any intention to file a claim. The effective date of an award of service connection based on an original claim “will be the date of receipt of the claim or the date entitlement arose, whichever is the later.” 38 C.F.R. § 3.400 (2017); see also 38 U.S.C. § 5110(a) (2012). Prior to March 24, 2015, “any communication or action indicating an intent to apply for one or more benefits under the laws administered by [VA] … may be considered an informal claim. Such informal claim must identify the benefit sought.” 38 C.F.R. § 3.155(a) (prior to March 24, 2015). However, “the mere existence of medical records generally cannot be construed as an informal claim; rather, there must be some intent by the claimant to apply for a benefit.” Criswell v. Nicholson, 20 Vet. App. 501, 504 (2006). As shown above, the Veteran filed his formal claim for service connection for PTSD in April 2011. No communication was received prior to April 2011 indicating any intent to file a claim – formal or informal. Therefore, the earliest possible effective date for service connection for PTSD is April 26, 2011 – the date his claim form was stamped as received by VA. The Board acknowledges that the Veteran’s representative has asserted in the September 2013 notice of disagreement that the Veteran sought treatment for PTSD in April 2008 at the VA medical center. The Board also acknowledges that April 2008 VA emergency department records do show the Veteran presented to the emergency room reporting diarrhea, anxiety, and flashbacks to his service, and that anxiety was diagnosed. See Records, received September 2011 at p.126 and 128 of 129. Unfortunately, however, as noted above, the mere existence of medical records generally does not constitute a claim for VA benefits. Prior to March 24, 2015, there was an exception provided in old 38 C.F.R. § 3.157 for records of VA hospitalization, but this only applied to effective dates for increased rating claims or requests to reopen previously denied claims – not to original service connection claims. Therefore, the Board concludes that the preponderance of the evidence is against finding entitlement to an effective date prior to April 26, 2011, for the award of service connection for PTSD; the benefit of the doubt rule is not for application. 3. Entitlement to an effective date prior to April 26, 2011, for the award of service connection for tinnitus A February 2013 rating decision awarded service connection for tinnitus, effective April 26, 2011. The Veteran seeks entitlement to an earlier effective date for service connection. On April 26, 2011 (stamped-received date), the Veteran filed a formal claim (Form 21-526) for service connection for tinnitus. There is no communication in the claims file prior to this April 2011 correspondence indicating any intention to file a claim. Because the Veteran filed his formal claim for service connection for tinnitus on April 26, 2011 (stamped-received date), the earliest possible effective date for service connection for tinnitus is April 26, 2011. The Veteran’s representative argues in his August 2018 brief that the Veteran’s effective date should relate back to April 2008 because that is when the Veteran first sought treatment at the VA medical center. However, as explained above, the mere existence of medical records generally does not constitute an informal claim for VA benefits. See Criswell v. Nicholson, 20 Vet. App. 501, 504 (2006). Also, as explained above, prior to March 24, 2015, there was an exception in old 38 C.F.R. § 3.157 for records of VA hospitalization, but that only applied to effective dates for increased rating claims or requests to reopen previously denied claims – not original claims for service connection. The Board adds that all of the Veteran’s VA treatment records from Loma Linda dated back in April 2008 have already been associated with the claims file. In light of the above, the Board concludes that entitlement to an effective date prior to April 26, 2011, for service connection for tinnitus is not warranted; as the preponderance of the evidence is against the claim, the benefit of the doubt rule is not for application. REASONS FOR REMAND 1. Entitlement to an evaluation in excess of 70 percent for PTSD is remanded. The Veteran’s PTSD is currently assigned a 70 percent rating effective April 26, 2011. The Veteran seeks a higher initial rating. See Rating decision, August 2012; Notice of disagreement, February 2013. A May 2017 record in the claims file shows a new VA examination was ordered for the Veteran’s PTSD. A copy of the examination report, however, has not been associated with the claims file. Therefore, the Board finds this matter should be remanded so that a copy of the Veteran’s most recent VA examination report (dated sometime since May 2017) may be associated with the claims file. In addition, all the Veteran’s more recent VA treatment records dated since May 2017 should be associated with the claims file. 2. Entitlement to a TDIU is remanded. The Veteran’s representative reported in a September 2013 notice of disagreement hat the Veteran had not worked since 2008 due to his service-connected PTSD (in arguing for entitlement to a 100 percent rating for PTSD). Therefore, the Board finds that the issue of entitlement to a TDIU has been implicitly raised as part and parcel to the PTSD rating claim. The Veteran himself reported in a statement attached to the August 2018 brief that he has been working as a licensed practical nurse (LPN) since 2010, with “occasional periods of unemployment” that he reports were due to his PTSD, and he reported he was presently employed at a nursing home. The Board finds that this matter should be remanded as intertwined with the PTSD rating claim being remanded herein, and that on remand, the Veteran should be asked to complete a Form 21-8940 detailing his employment history since April 2011. 3. Entitlement to service connection for residuals of a right tibia fracture is remanded. The Veteran asserts that he has a right leg disability due to a tibial fracture he incurred during training, either basic training or advanced individual training (AIT). The available service treatment records associated with the claims file include a July 2002 x-ray report that notes a history of a November 2001 right tibial fracture. Findings were noted of “remodeling of an oblique fracture involving the mid portion of the right tibia. The fracture line is still faintly visible and there is slight posterior bowing of the tibia. There is near anatomic alignment.” An impression was noted of “remodeling fracture deformity of the mid right tibia as above.” See Service treatment records at p.9 of 15 (emphasis added). In support of his claim, the Veteran has essentially alleged that his right leg fracture did not heal at the correct angle. See Hearing transcript at p.22. A July 2012 VA examination report noted a diagnosis of “right tibia fracture in 2001 - was in the reserves” was noted by the VA examiner. A November 2012 addendum medical opinion shows the same examiner essentially opined that the Veteran’s right leg condition was due to the 2001 fracture injury. The claims file includes no treatment records, including no copy of any treatment in November 2001 (during Reserve service) for a right tibia fracture, and no separation examination report. Also, there is no record of the Veteran’s periods of active duty for training (ADT) and inactive duty for training (IDT) between January 2001 and January 2003. The RO requested the Veteran’s service treatment records from the RMC in July 2011, and a negative response was received in February 2012. However, the SF Form 180 indicates a request should be made for the Veteran’s service treatment records to the NPRC. Also, the SF Form 180 indicates a request should be made to the U.S. Army Human Resources Command for copies of the Veteran’s personnel records. Therefore, the Board finds this matter should be remanded so that copies of all the Veteran’s service treatment records and service personnel records may be requested from the NPRC – if a negative response is received for the service personnel records, then a request should be made for the personnel records to the U.S. Army Human Resources Command. Records from both his active duty service, and prior Reserve service, should be requested. Should a negative reply be received for any of the requested service records as outlined above, then a request for the missing records should be made to the Veteran’s unit. In that regard, the Board acknowledges that in September 2011, the RO mailed a request to the Veteran’s unit, which was returned as undeliverable. Subsequent requests were sent by the RO to the Veteran’s unit in November 2011 and February 2012, but no written response was ever received. All three of these written requests, however, appear to have been sent to incorrect addresses, as they do not match the addresses shown on January 2003 orders. See Personnel records at p.5-7 of 7. The Board acknowledges that an April 2012 Report of Contact shows the RO telephoned the unit, was referred to another number, and was told no record could be found, and that in December 2011, the Veteran reported “much” of his records were unavailable. Regardless, if any negative response is received from the NPRC and the U.S. Army Human Resources Command regarding a request for the Veteran’s service treatment records or service personnel records, then a request should be made to the Veteran’s unit for the records at the addresses shown on the Veteran’s January 2003 orders, which are as follows: Department of the Army 437th Med. Co. (Ground Ambulance) 14945 4th Street Riverside CA 92518 and Commander, 437th Med Co. Ground Ambul 5255 4th Street, Bldg 2604 March ARB Moreno, CA 92552. Also, on remand, the RO should seek from the Veteran’s unit his dates of ADT and IDT for the period from January 2001 to January 2003 (because the July 2002 x-ray indicates the right leg tibia fracture occurred in November 2001, but it is unclear whether that was during a period of ADT or IDT). 3. Entitlement to service connection for a low back disability is remanded. The Veteran also asserts that he has a low back disability due to his active service. He testified at the Board hearing that he has a low back disability due to his duties in service carrying patients as a combat medic (including patients weighing over 200 pounds), and due to an alleged fall backwards five or six feet from an ambulance landing onto rocks. The Board acknowledges that the Veteran’s available service personnel records in the claims file note that as a combat medic in Kuwait, the Veteran “spent endless hours comforting and transporting patients from hospital to hospital and the constant strain of loading and unloading patients off of helicopters.” See Personnel records at p.1 of 7. The Board also acknowledges that the Veteran reports that he works as a licensed practical nurse (LPN). See Brief, August 2018 at p.13. An April 2012 VA emergency department record shows the Veteran complained of low back pain and a lumbar strain was diagnosed. As discussed above, most of the Veteran’s service treatment records are missing from the claims file. Therefore, the Board finds that this matter should be remanded so that any outstanding, available service treatment records may be associated with the claims file. Furthermore, a July 2012 VA examination report shows the examiner noted a diagnosis of “low back pain.” The examiner lumped four claimed disabilities together and checked one box indicating he opined that all four are related to the Veteran’s active service, simply reasoning they “started in service.” The Board finds this VA examination report to be too vague upon which to base a decision on the claim with respect to both the diagnosis and the rationale. The Board finds that on remand, a new VA examination should be performed, including an x-ray report, and that the VA examiner should further clarify the nature of any current low back disability (beyond merely “low back pain”) and provide an etiological opinion with a more detailed rationale. 4. Entitlement to service connection for bilateral hearing loss is remanded. The Veteran claims that he has bilateral hearing loss due to his active service. The Veteran served as a combat medic in Kuwait. His February 2004 post-deployment health assessment form shows he checked the box noting that he was exposed to loud noise “often.” See Service treatment records at p.5 of 15. The Veteran was afforded an August 2012 VA audiological examination, but audiological testing revealed pure tone thresholds and speech recognition scores that do not meet the VA regulatory criteria for a current hearing loss disability – pure tone thresholds were 20 to 25 decibels at 500 to 4000 hertz bilaterally, and speech recognition scores were 100 percent for the left ear, and 94 percent in the right ear. See 38 C.F.R. § 3.385 (2017). More recent May 2016 audiology records from the VA medical center show audiometric testing was performed, and it was noted that hearing thresholds in both ears were “normal” between 500 and 4000 hertz. However, the results of the audiometric testing were not specifically noted. See CAPRI, received May 2017 at p.81 of 522. Therefore, giving the Veteran all benefit of the doubt, the Board finds this matter should be remanded so that the results of the May 2016 VA audiological testing may be associated with the claims file before a decision can be made on the claim. 5. Entitlement to service connection for liver disease is remanded. The Veteran claims that he has liver disease due to his active service. July 2009 VA treatment records show diagnosed fatty liver disease. See Records, received September 2011 at p.22 and 45 of 129. The Veteran’s representative recently argued in an August 2018 brief (see p.6) that the Veteran’s liver disease was caused by alcohol abuse secondary to service-connected PTSD. The Board notes, however, that service connection for alcohol abuse has not been established. If the Veteran wishes to file a complete claim for such, the Board notes that effective March 24, 2015, VA amended its regulations requiring that a claim for VA compensation be provided on a form prescribed by the Secretary. See 38 C.F.R. §§ 3.1(p) and 3.150(a) (2017). Therefore, should the Veteran wish to file a claim for service connection for service connection for alcohol abuse as secondary to his service-connected PTSD, he should do so on the required form (i.e., Form 21-526), which is available online at https://www.ebenefits.va.gov/ebenefits/ and at the local RO. Regardless, the Board is cognizant that some VA treatment records note the Veteran’s liver disease as “nonalcoholic,” although the Veteran did report a history to VA clinicians of drinking heavily for two years after separation, and also a history in April 2008 of drinking 12 beers per day three or four days per week for six months. See Records, received May 2017 at p.330 of 522, and received May 2011 at p.1 of 9; CAPRI, received September 2011 at p.126 of 129. The Veteran’s VA treatment records indicate that the Veteran’s weight is a risk factor. See Records, received September 2011 at p.45 of 129. As discussed above, only a few of the Veteran’s service treatment records have been associated with the claims file. Therefore, the Board finds that the claimed liver disease should be remanded so that any other available service treatment records may be associated with the claims file (which may show, among other things, the Veteran’s weight in service). Furthermore, the Board finds that this matter should be remanded for a new VA medical opinion. A July 2012 VA examination report shows that the examiner checked a box indicating he opined that five conditions, including the Veteran’s fatty liver disease, are at least as likely as not related to the Veteran’s active service. However, the VA examiner’s reasoning indicates he checked that box in error – he reasoned “except for liver which was diagnosed in 2010, the rest have been started in service.” Therefore, the examiner gave a conflicting opinion. The RO requested an addendum opinion to address whether the Veteran had an undiagnosed illness related to his Gulf War service. A November 2012 addendum opinion shows the examiner opined that the Veteran’s fatty liver disease is a “diagnosed illness” but with no etiology, and “may” be related to his environmental exposures in “Iraq.” However, as stated by the examiner, the Veteran’s liver disease has a diagnosis – fatty liver disease – it therefore cannot constitute an undiagnosed illness. Furthermore, his VA treatment records certainly indicate etiology – weight gain and possibly alcohol. See Records, received September 2011 at p.45 of 129; Records, received September 2011 at p.44 of 129. Therefore, the Board finds that a new VA medical opinion should be obtained to clarify whether the Veteran’s fatty liver disease had its onset in service or is otherwise related to his active service on a direct basis. The examiner should also address whether any weight gain in service (if any is shown) was a factor, and whether the Veteran’s fatty liver disease was caused by alcohol abuse. Also, the VA medical opinion should address a more recent February 2013 VA treatment record showing a liver biopsy revealed steatohepatitis. See Records, received May 2017 at p.366 of 522. 6. Entitlement to service connection for headaches is remanded. The Veteran claims that he has headaches due to his active service. He testified at the Board hearing, and wrote in an August 2018 statement, that he began experiencing migraine headaches in service after his reported fall from an ambulance in which he alleges he injured his back. He further alleges that the burn pits in Kuwait caused his migraines to become more frequent. The Veteran’s February 2004 post-deployment health assessment shows he checked the box denying that he experienced headaches. The other few service treatment records in the claims file show no complaints of headaches. A July 2012 VA examination report shows the VA examiner noted the Veteran was diagnosed with tension headaches in 2004 in service. The examiner checked a box indicating he opined that five listed conditions, including the Veteran’s tension headaches, are at least as likely as not related to his active service, reasoning only they “started in service.” As shown above, however, there is no record of complaint or diagnosis of headaches in the few service treatment records that have been associated with the claims file - in fact, the Veteran specifically denied experiencing headaches on his February 2004 post-deployment questionnaire. At this time, the Board finds that this matter should be remanded so that any other available, outstanding service treatment records may be obtained (see discussion regarding outstanding service treatment records above). As applicable to the claims for service connection above, the Veteran and his representative contend that the Veteran’s experience as a combat medic and LPN should qualify him to provide medical expert opinions. The issue, however, is not merely medical training, but rather whether the training includes the expertise to make etiological assessments for the medical condition at issue. See Black v. Brown, 10 Vet. App. 279, 284 (1997). As a general matter, the training and education of an LPN is quite different from that of a nurse practitioner. Cf. Cox v. Nicholson, 20 Vet. App. 563, 569 (2007). An LPN has generally completed a 12- to 14-month post-high-school education course that focuses on basic nursing care. See Sue C. Delaune & Patricia K. Ladner, Fundamentals Of Nursing: Standards And Practice 41 (2d ed. 2002). Based on general certification requirements, an LPN does not have the kind of medical knowledge and training that a certified registered nurse practitioner is required to obtain and must generally work under the guidance of a licensed provider such as a registered nurse. See DeLaune & Ladner, supra. An LPN does not have the training to diagnose conditions as a nurse practitioner does. Id. Although there is evidence that as a combat medic he provided first responder and evacuation care in a combat environment, there is no information as to the particular training the Veteran may have received as a medic to show that he has the medical competence to contribute to his own diagnosis, or analyze the probable cause of his medical conditions. Therefore, the Board will obtain competent medical opinions as required. 7. Entitlement to an initial evaluation in excess of 10 percent for irritable bowel syndrome (IBS). 8. Entitlement to an effective date prior to April 26, 2011, for the award of service connection for IBS. A May 2015 rating decision granted service connection for IBS and assigned a 10 percent rating, effective April 26, 2011. The Veteran filed a May 2015 notice of disagreement as to the initial rating and the effective date. A July 2016 SOC was issued, but it was not mailed to the Veteran’s last known address. One month prior, June 2016 CAPRI records show a new address for the Veteran on P---- Street. See CAPRI, received May 2017 at p.102 of 522. At the Board hearing, and in an August 2018 brief, the Veteran’s representative indicated the Veteran wished to file an appeal for the IBS initial rating claim, and for the earlier effective date claim, but that the representative never received a copy of the July 2016 SOC. See Brief, August 9, 2018 at p.15 of 56. The Veteran’s representative also alleged in May 2018 correspondence that he notified VA back in 2016 of a change of address (albeit there is no record of such in 2016 in the claims file). Regardless, as the July 2016 SOC was never mailed to the Veteran’s last known address, the Board finds that these two matters involving entitlement to a higher initial rating for IBS, and entitlement to an earlier effective date for service connection for IBS, should be remanded herein for the issuance of a SOC to the last known mailing addresses of the Veteran (P--- Street) and of his representative (PO Box). See Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). The matters are REMANDED for the following action: 1. Ask the Veteran to provide a completed Form 21-8940 relating to the inferred TDIU claim – please ask the Veteran to provide all employment information from April 2011 to present. 2. Associate with the claims file a copy of any VA examination report relating to the Veteran’s PTSD dated since May 2017 (as one was ordered in May 2017). 3. Associate with the claims file all of the Veteran’s more recent VA treatment records dated since May 2017. 4. Request from the NPRC copies of the Veteran’s service treatment records and service personnel records for the Veteran’s reservist service between January 2001 and January 2003, and from his regular active duty from January 2003 to March 2004. If a negative response is received for the request for the service personnel records, then send a request to the U.S. Army Human Resources Command. 5. After the above development in paragraph (4) has been completed, ask the Veteran’s unit for records of his periods of ADT and IDT between January 2001 and January 2003 (with particular emphasis in November 2001). Also, if any of the Veteran’s service records were unable to be obtained from the NPRC or U.S. Army Human Resources Command as directed in paragraph (4), then ask the Veteran’s unit for copies of the missing service records as well. Requests to the Veteran’s unit should be mailed to: Department of the Army 437th Med. Co. (Ground Ambulance) 14945 4th Street Riverside CA 92518 And Commander, 437th Med Co. Ground Ambul. 5255 4th Street, Bldg 2604 March ARB Moreno, CA 92552. 6. After all of the above development in paragraphs (3) to (5) has been completed, afford the Veteran a new VA examination to address the nature and etiology of his claimed low back disability. The complete claims folder must be provided to the examiner for review in conjunction with the examination, and the examiner must note that the claims folder has been reviewed. An x-ray must be performed. The examiner should opine as to whether it is “at least as likely as not” (50 percent or greater probability) that any low back disability identified on examination is related to the Veteran’s active service. Please ask the VA examiner to address the fact that the box for “IVDS” was checked on the July 2012 VA examination report, and to address the April 2012 VA treatment record showing a diagnosed lumbar strain. Any opinion must be accompanied by a complete rationale. 7. Associate with the claims file a copy of the results of the VA audiological testing performed in May 2016 (i.e., the specific pure tone thresholds). 8. After all of the development in paragraphs (3) to (5) has been completed, obtain a VA medical opinion based on a review of the entire claims file, including this remand, to clarify whether it is “at least as likely as not” (50 percent or greater probability) that the Veteran’s fatty liver disease, and any other liver disease shown, had its onset in service or is otherwise related to the Veteran’s active service on a direct basis. An examination is necessary if required by the examiner to form an opinion. Please explain to the VA examiner that although the Veteran’s exposure to burn pits is conceded, no opinion as to whether the Veteran has an undiagnosed illness is requested. The examiner is not, however, precluded from finding that the Veteran’s fatty liver disease was directly caused exposure to burn pits in service. Also, please ask the VA examiner to address whether the Veteran’s fatty liver disease was caused by weight gain or alcohol abuse. If weight gain is found to be a factor, please ask the examiner to further address whether the Veteran’s fatty liver disease is related to weight gain during service (if any is shown). Please direct the examiner’s attention to the CAPRI records received May 2011 at p.1 of 9, received May 2017 at p.330 of 522, and received September 2011 at p.126 of 129. Also, please ask the VA examiner to address a more recent February 2013 VA treatment record showing a liver biopsy revealed steatohepatitis. See CAPRI, received May 2017 at p.366 of 522. Any opinion must be accompanied by a complete rationale. Issue a SOC (not a SSOC) with regard to the issues of entitlement to a higher initial rating for the Veteran’s IBS, and entitlement to an earlier effective date for service connection for IBS. The SOC should be mailed to the representative’s last known address (PO Box – see May 2018 correspondence), and to the Veteran’s last known address on P---- Street. If the benefits sought cannot be granted, the Veteran should be informed of his appellate rights and of the actions necessary to perfect an appeal on the issue(s). Thereafter, the issue(s) are to be returned to the Board only if an adequate and timely substantive appeal is filed. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Juliano, Counsel