Citation Nr: 1808091 Decision Date: 02/08/18 Archive Date: 02/20/18 DOCKET NO. 14-22 795 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Whether new and material evidence has been received to reopen a previously denied service connection claim for hypertension. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for sarcoidosis. 4. Entitlement to service connection for high cholesterol. 5. Entitlement to service connection for hypogonadism. 6. Entitlement to service connection for hypoglycemia. 7. Entitlement to an increased rating for renal insufficiency associated with diabetes mellitus, currently rated as 80 percent disabling. 8. Entitlement to an increased rating for diabetes mellitus, currently rated as 40 percent disabling prior to November 4, 2017 and 20 percent disabling thereafter. 9. Entitlement to an increased rating for peripheral neuropathy, right lower extremity associated with diabetes mellitus, currently rated as 10 percent disabling prior to November 4, 2017 and 20 percent thereafter. 10. Entitlement to an increased rating for peripheral neuropathy, left lower extremity associated with diabetes mellitus, currently rated as 10 percent disabling prior to November 4, 2017 and 20 percent thereafter. 11. Entitlement to an effective date prior to October 6, 2011 for the award of special monthly compensation (SMC) based upon loss of use of a creative organ. 12. Entitlement to an effective date prior to June 14, 2014 for a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. D. Simpson, Counsel INTRODUCTION The Veteran had active duty service from February 1994 to February 2000. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2012 decision by the Regional Office (RO) of the Department of Veterans Affairs (VA) in Atlanta, Georgia that denied the benefits sought on appeal. In a February 2015 rating decision, the RO granted entitlement to a TDIU effective June 14, 2014. Although the effective date of that grant was based in part on the date of a formal TDIU application form (VA Form 21-8940), the issue of TDIU is also part and parcel of the increased rating claims on appeal. Roberson v. Principi, 251 F.3d 1378, 1384 (2001); Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, the date of those increased rating claims could result in an earlier effective date for TDIU if the criteria for TDIU were met prior to June 14, 2014. The Board has therefore included the issue of entitlement to a TDIU prior to June 14, 2014 on appeal. In August 2017, the Veteran had a Board videoconference hearing before the undersigned Veterans Law Judge. A hearing transcript is of record. In November 2017, the Veteran appointed the current state service representative and the Board recognizes this change in representation. The issues of service connection for sarcoidosis and hypogonadism and increased ratings for renal insufficiency, diabetes and right and left peripheral neuropathy of the lower extremities are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. In a June 2003 decision, the RO denied the Veteran's claim of entitlement to service connection for hypertension. The Veteran did not appeal that decision, and new and material evidence was not received within one year of its issuance. 2. The evidence shows that Veteran developed hypertension secondary to service-connected diabetes. 3. The claimed cholesterol disorder is not a disability for VA benefits purposes. 4. Hypoglycemia is fully contemplated in the rating criteria as part of the diabetes process. 5. The Veteran's service-connected erectile dysfunction is related to service-connected diabetes. 6. The evidence reflects that the Veteran did not file a service connection claim for erectile dysfunction prior to October 6, 2011 and did not have a pending increased rating claim for diabetes. 7. On October 6, 2011, the RO received a claim for an increased rating for diabetes and it is not factually ascertainable that an increase in disability occurred in the one-year period prior to October 6, 2011 and there was no claim, formal or informal, filed prior to October 6, 2011. 8. Throughout the entire appeal period, the Veteran's service connected disabilities render him unable to secure or follow substantially gainful employment. CONCLUSIONS OF LAW 1. The June 2003 RO decision denying the claim of entitlement to service connection for hypertension is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2017). 2. The evidence received since the June 2003 decision is new and material as to the issue of service connection for hypertension and the claim is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The criteria for entitlement to service connection for hypertension are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 4. The criteria for service connection for a cholesterol disorder are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. § 3.303. 5. The criteria for entitlement to service connection for hypoglycemia are not met. 38 U.S.C. §§ 1110, 1155, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 4.14, 4.119, Diagnostic Code 7913. 6. The criteria for an effective date prior to October 6, 2011 for the grant of SMC based upon loss of use of a creative organ have not been met. 38 U.S.C. §§ 5107(b), 5110(g), 7105(d)(3) (2012); 38 C.F.R. §§ 3.104, 3.114(a) (2015), 3.155(a) (in effective prior to March 24, 2015), 3.156 (a)-(b) (2015), 3.157(b)(1) (in effective prior to March 24, 2015), 3.350(a), 4.119, Diagnostic Code 7913, 20.302, 20.1103 (2015). 7. Prior to June 14, 2014, with reasonable doubt resolved in favor of the Veteran, the criteria for a TDIU are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.400, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to notify and assist The Veterans Claims Assistance Act of 2000 as amended (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). The claims of service connection for a cholesterol disorder and hypoglycemia are being denied as a matter of law. As such, the VCAA is inapplicable to these claims. Livesay v. Principi, 15 Vet App 165, 178 (2001); Smith v. Gober, 14 Vet. App. 227, 231-32 (2000); VAOPGCPREC 5-2004 (2004), 69 Fed. Reg. 59989 (2004). The instant decision regarding the hypertension and TDIU issues results in a complete grant of the benefits sought and consideration of VCAA compliance for these issues is not necessary. Upon receipt of a complete or substantially complete application for benefits, the VCAA requires VA to notify the claimant and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C. § 5103(a) (2012); 38 C.F.R. § 3.159(b) (2017). In this case, the claim for an earlier effective date arise from the Veteran's disagreement with the effective date assigned in connection with the initial award for special monthly compensation for loss of use of a creative organ. The courts have held, and VA's General Counsel has agreed, that where an underlying claim has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional notice or there is no prejudice from absent notice. Hartman v. Nicholson, 483 F.3d 1311, 1314-15 (Fed. Cir. 2007). The duty to notify is satisfied. VA is also required to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). As shown by the discussion below, all the pertinent evidence is already of record with respect to the Veteran's earlier effective date claim in dispute. The Veteran has not identified and the record does not show that there is outstanding evidence relevant to the earlier effective date claim. No further assistance is necessary. For the reasons set forth above, the Board finds that VA has complied with the notification and assistance requirements. The claims addressed below are ready to be considered on the merits. II. New and Material Evidence In June 2003, the RO denied service connection for hypertension. The Veteran did not appeal this decision and no new and material evidence was received within one year of this decision. As such, it became final. Bond v. Shinseki, 659 F.3d 1362, 1367-68 (Fed. Cir. 2011). As a general rule, a claim shall be reopened and reviewed if new and material evidence is presented or secured with respect to a claim that is final. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Under 38 C.F.R. § 3.156(a), new evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In June 2003, the RO denied service connection for these claims due to an absence of a current disability. Since the June 2003 RO decision, new evidence has been submitted. November 2017 VA examinations confirm a current hypertension disability and related it to service-connected diabetes. As this evidence relates to the basis for the prior denial and raises a reasonable possibility of substantiating the claim, it is new and material. Reopening of the claim for service connection for hypertension is therefore warranted. 38 C.F.R. § 3.156. III. Service connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease, however remote, are service connected, unless clearly attributable to intercurrent causes. Continuity of symptomatology is required only where the condition noted during service is not in fact shown to be chronic or the diagnosis of chronicity may be legitimately questioned. The provisions of 38 C.F.R. § 3.303(b) apply only to the specific chronic diseases listed in 38 U.S.C. § 1101(3) and 38 C.F.R. § 3.309(a), which include hypertension. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A. Hypertension In addition to the regulations noted above, service connection may also be established on a secondary basis 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) (2017). 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) caused by or (b) aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2017); Allen v. Brown, 7 Vet. App. 439 (1995). VA has amended 38 C.F.R. § 3.310 to explicitly incorporate the holding in Allen, except that it will not concede aggravation unless a baseline for the claimed disability can be established with evidence created prior to any aggravation. 38 C.F.R. § 3.310(b). The Veteran is service-connected for diabetes. The February 2012 VA examination report included an assessment of idiopathic hypertension. Meanwhile, the November 2017 VA examination report confirmed that the Veteran currently has hypertension and it is due to service-connected diabetes. The VA examiner cited the onset of hypertension following the diabetes diagnosis. The Board notes that in a November 2017 rating decision code sheet, the RO declined to recognize hypertension as a diabetes complication because the medical evidence showed hypertension developed before nephropathy. However, the Board may not exercise independent judgment on medical questions. See also Colvin v. Derwinski, 1 Vet. App. 171 (1991). The Veteran has a complicated medical history and the Board accepts the November 2017 VA examiner's report as sufficient to show a nexus. Given the above, the Board finds that the medical evidence regarding a nexus for hypertension to service-connected diabetes is in a relative state of equipoise. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for hypertension secondary to service-connected diabetes is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. B. Cholesterol A "disability" for the purposes of awarding VA disability benefits is not only a disease or an injury, but also any "other physical or mental defect." 38 U.S.C. § 1701(1); Allen v. Brown, 7 Vet. App. 439, 444-45 (1995) (applying definition of disability in section 1701(1) to statutes describing "eligibility for disability compensation for service connected disabilities"). The Court in Allen also indicated that disability for VA compensation purposes refers to impairment of earning capacity due to a disease or injury, rather than to a disease or injury itself. Id. VA treatment records show that by August 2008 the Veteran had hyperlipidemia. Hyperlipidemia is a general term for elevated concentrations of any or all of the lipids in the plasma, including hypertriglycerides and hypercholesterolemia (high cholesterol). Dorland's Illustrated Medical Dictionary 903 (31st ed. 2007). In this regard, the Board notes that reference to a medical dictionary to assist in understanding the nature of a disorder is not improper. See O'Bryan v. McDonald, 771 F.3d 1376, 1380 (Fed. Cir. 2014) (referencing Dorland's for nature of and symptoms associated with a condition); Prokarym v. McDonald, 27 Vet. App. 307, 310 (2015) (defining DC term "severe" using the New Oxford American Dictionary and online Merriam-Webster Dictionary); Terry v. Principi, 340 F.3d 1378, 1383 (Fed. Cir. 2003) (concluding statute was not ambiguous using definitions from Dorland's). VA has in its rulemaking capacity similarly indicated that high cholesterol does not fall within VA's definition of disability for which compensation is warranted. 61 Fed. Reg. 20440, 20445 (May 7, 1996) (supplementary information preceding revisions to criteria for evaluating endocrine system indicating that hyperlipidemia, elevated triglycerides, and elevated cholesterol "are actually laboratory test results, and are not, in and of themselves, disabilities"). The finding of hyperlipidemia is not shown to be associated with any disability-much less one that was incurred in or aggravated by active service. As such, there is no competent evidence of a current disability upon which to predicate a grant of service connection on any basis, and, hence, no valid claim for service connection. Rabideau v. Derwinski, 2 Vet. App 141, 144 (1992). As such, service connection for high cholesterol must be denied as a matter of law, and the benefit of the doubt doctrine is therefore not for application. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994); 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. C. Hypoglycemia Hypoglycemia is defined as low blood sugar. https://medlineplus.gov/ hypoglycemia.html (last visited January 29, 2018). The Veteran is service-connected for diabetes. 38 C.F.R. § 4.119, Diagnostic Code 7913. The applicable rating criteria for diabetes specifically contemplate hypoglycemic reactions from treatment. Id. A separate rating for hypoglycemia, in addition the current diabetes disability in effect would constitute impermissible pyramiding. 38 C.F.R. § 4.14. In other words, hypoglycemia is essentially subsumed by the current rating criteria for service-connected diabetes. As such, service connection for hypoglycemia must be denied as a matter of law, and the benefit of the doubt doctrine is therefore not for application. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994); 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. IV. Earlier effective date for SMC based upon loss of use Generally, except as otherwise provided, the effective date of an award of compensation based on an original claim will be the day following separation from active service or the date entitlement arose, if the claim is received within one year after separation from service; otherwise, the date of receipt of the claim, or the date entitlement arose, whichever is later. See 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. For increased rating claims, the effective date of an award is the earliest date as of which it is factually ascertainable that an increase in disability had occurred if the claim is received within one year from such date; otherwise, the effective date of the award is the later of the date of receipt of the claim or the date entitlement arose. 38 U.S.C. § 5110; 38 C.F.R. § 3.400(o). VA regulations allow for the assignment of an increased rating up to one year prior to receipt of a formal claim for increase, when it is factually ascertainable that an increase in disability had occurred. 38 C.F.R. § 3.400(o)(2). Prior to March 24, 2015, a claim could be either a formal or an informal written communication "requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit." See 38 C.F.R. § 3.1(p) (2014); But see 38 C.F.R. § 3.1 (p) (2016) (now providing that a "claim" must be submitted on an application form prescribed by the Secretary); 79 Fed. Reg. 57,696 (Sept. 25, 2014) (eliminating informal claims by requiring that, effective March 24, 2015, claims be filed on standard forms). It has been held that an intent to apply for benefits is an essential element of any claim, whether formal or informal, and, further, the intent must be communicated in writing. . . . It follows logically that where there can be found no intent to apply for VA benefits, a claim for entitlement to such benefits has not been reasonably raised. Criswell v. Nicholson, 20 Vet. App. 501, 503 (2006); see MacPhee v. Nicholson, 459 F.3d 1323, 1326-27 (Fed. Cir. 2006) (holding that the plain language of the regulations requires a claimant to have intent to file a claim for VA benefits). Thus, a claim, whether "formal" or "informal," must be "in writing" in order to be considered a "claim" or "application" for benefits. See Rodriguez v. West, 189 F.3d 1351, 1354 (Fed. Cir. 1999). The Veteran filed for entitlement to service connection for ED and to an increased rating for diabetes on October 6, 2011. A September 2012 RO decision denied an increased rating for diabetes and granted SMC based on loss of use of a creative organ with an October 6, 2011 effective date. The RO last adjudicated an increased rating claim for diabetes in a final June 2003 decision. Prior to October 6, 2011, there is no communication that could be construed as an informal claim for either service connection for ED or an increased rating for diabetes. 38 C.F.R. § 3.1(p) (2014). VA treatment records indicate that ED was manifested prior to October 6, 2010. At the August 2017 hearing, the Veteran dated the ED onset to 2005. August 2017 hearing transcript p. 8. Thus, the evidence weighs against a finding of ED onset secondary to diabetes within a year of the October 6, 2011 claim for increase for diabetes. 38 C.F.R. § 3.400(o). In summary, the evidence weighs against this claim and the reasonable doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. An effective date prior to October 6, 2011 for the award of (SMC) based upon loss of use of a creative organ must be denied. V. Entitlement to TDIU prior to June 14, 2014 VA will grant a TDIU when the evidence shows that the Veteran is precluded, by reason of his service-connected disabilities, from securing and following "substantially gainful employment" consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16; VAOPGCPREC 75-91. The central inquiry is, "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The regulations provide that if there is only one such disability, it must be rated at 60 percent or more; and if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Disabilities resulting from common etiology or a single accident or disabilities affecting a single body system will be considered as one disability for the above purposes of one 60 percent disability or one 40 percent disability. 38 C.F.R. § 4.16(a). The Board must evaluate whether there are circumstances in the Veteran's case, apart from any nonservice-connected disability and advancing age, which would justify a TDIU due solely to the service-connected disabilities. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993); see also Blackburn v. Brown, 5 Vet. App. 375 (1993). Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). From October 6, 2011, the date of the claims adjudicated in the instant appeal, the Veteran is service-connected for renal insufficiency, rated as 80 percent disabling; diabetes, rated as 40 percent disabling prior to November 4, 2017 and 20 percent thereafter; peripheral neuropathy of the right and left lower extremities, each rated as 10 percent disabling prior to November 4, 2017 and 20 percent thereafter; supraventricular tachycardia, 10 percent disabling; and then for allergic rhinoconjunctivitis, osteotomy left fifth toe, and dermatitis, all noncompensable. His combined rating is 90 percent. He meets the percentage criteria for a TDIU laid out in 38 C.F.R. § 4.16(a) for the entire appeals period. Even so, to grant TDIU it must be found that the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. Consequently, the Board must determine whether the Veteran's service-connected disabilities combine to preclude him from engaging in substantially gainful employment (work that is more than marginal, which permits the individual to earn a "living wage"). Moore v. Derwinski, 1 Vet. App. 356 (1991). The fact that a Veteran may be unemployed or has difficulty obtaining employment is not determinative. The ultimate question is whether the Veteran, because of service-connected disabilities, is incapable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose, 4 Vet. App. at 363. Inability to work due to advancing age may not be considered. 38 C.F.R. §§ 3.341(a), 4.19 (2017). In making its determination, VA considers such factors as the extent of the service-connected disabilities, and employment and educational background. See 38 C.F.R. §§ 3.340, 3.341, 4.16(b), 4.19. As to the Veteran's employment history, he reported that he last worked full time in December 2010. He had been employed as a corrections officer. He also worked on a part time basis from May 2011 to June 2011. He had a high school education and additional vocational training. See June 2014 VA Form 21-8940 Veteran's Application for Increased Compensation based on Unemployability. At the August 2017 hearing, the Veteran stated that by 2010 he had significant difficulty performing physical work duties due to poor diabetes control and was being reprimanded for missing work due to VA medical appointments. August 2017 hearing transcript p. 25. He left his longstanding job in November 2010. Id. at p. 26. The available medical records are generally consistent with his reports of physical limitations due to service-connected disabilities. Most notably, the April 2012 VA examination report indicated that the Veteran had fatigue with exertion due to service-connected renal disease. In light of the above, the Board finds that the shows that throughout the entire claims period, the Veteran's service connected disabilities rendered him unable to secure or follow substantially gainful employment. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) ("applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner"; "neither the statute nor the relevant regulations require the combined effect [of disabilities] to be assessed by a medical expert"). Entitlement to a TDIU prior to June 14, 2014 is therefore warranted. ORDER The application to reopen the claim for service connection for hypertension is granted. Service connection for hypertension is granted. Service connection for high cholesterol is denied. Service connection for hypoglycemia is denied. An effective date prior to October 6, 2011 for the award of SMC based upon loss of use of a creative organ is denied. Entitlement to a TDIU prior to June 14, 2014 is granted, subject to controlling regulations governing the payment of monetary awards. REMAND Sarcoidosis and hypogonadism VA medical opinions and an additional medical record requests are needed for these claims. 38 C.F.R. § 3.159. The Veteran provided competent and credible reports about in-service environmental exposures and breathing problems. He asserts these symptoms are a nexus for sarcoidosis, formally diagnosed in 2004. See February 2005 VA treatment records (indicating a December 2004 diagnosis for pulmonary sarcoidosis). Then, he asserts that he developed hypogonadism secondary to prednisone treatment for sarcoidosis. (August 2017 hearing transcript, p. 17). The available medical records are silent with regards to a nexus for either claim. Sarcoidosis and secondary hypogonadism are complex disease processes, and the Board finds the available evidence is insufficient to resolve the issue of a nexus. A request for the outstanding medical records referenced above and medical opinions is needed as instructed below. Kidney, diabetes, and bilateral peripheral neuropathy of the lower extremities The Veteran has identified medical records for these claims that are not associated with the record and additional efforts to obtain them are necessary. At the August 2017 hearing, the Veteran reported that there were outstanding medical records concerning all of his medical conditions. See August 2017 hearing transcript p. 6. The medical evidence (found in the Legacy Content Manager electronic folder (efolder)) from October 2010 consists of VA treatment records from VA Medical Centers in Richmond, Dublin, Augusta, Atlanta and Gainesville. No private medical records have been obtained. Notably, in September 2014, the Veteran submitted private medical records releases for Riverside Williamsburg Urgent Care and FirstMed of Williamsburg concerning all claims. No action has been taken to obtain these private medical records and further assistance is necessary. 38 C.F.R. § 3.159(c). Then, it appears VA treatment records from approximately March 2014 through December 2014 are unavailable. The Legacy Content Manager efolder includes VA treatment records from the Atlanta VA Medical Center (VAMC) from October 2011 to March 2014 and then from January 2015. Review of these medical records indicates he had ongoing VAMC treatment for the March 2014 through December 2014 period. These VA treatment records should be obtained. Accordingly, the claims remaining on appeal are REMANDED for the following action: 1. VA treatment records - obtain and associate with record the following VA treatment records for the Veteran: (a) VA treatment records from November 2017, (b) Atlanta VAMC treatment records from March 1, 2014 through December 31, 2014. 2. Private medical records - request that the Veteran identify the December 2004 medical records concerning initial diagnosis for pulmonary sarcoidosis and February 2005 pulmonology records concerning pulmonary sarcoidosis that are referenced in February 2005 VAMC Hampton emergency department records. Request the Veteran identify any medical provider that informed him of a secondary nexus between sarcoidosis medication and hypogonadism. Request that the Veteran complete another authorization form for the release of medical records from Riverside Williamsburg Urgent Family Care and FirstMed of Williamsburg. Inform the Veteran that VA may request private medical records on his behalf if he completes and returns authorization forms for the release of private medical records. Alternatively, he may secure these private medical records and submit them to VA. Notify the Veteran of any inability to obtain identified private medical records and allow him an opportunity to respond. 3. Then, contact an appropriately qualified clinician to provide a VA medical nexus opinion regarding sarcoidosis and hypogonadism. The clinician should conduct a complete review of the electronic claims folder. (If the clinician indicates physical examination is needed, this should be scheduled). (a) Is it at least as likely as not that sarcoidosis is the result of in-service environmental exposures in active service, or otherwise was initially manifest in service? (b) If so, is it at least as likely as not that hypogonadism is caused or aggravated by sarcoidosis medication, specifically prednisone, used for sarcoidosis treatment? The medical opinion must specifically address both causation and aggravation elements. (c) The examiner should provide comprehensive reasons for this opinion. (d) The examiner is advised that the Veteran is competent to report symptoms and observable history. His reports concerning in-service environmental exposures and difficulty breathing must be considered. (e) The absence of evidence of treatment for symptoms in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. 4. If any benefit remains denied, issue a supplemental statement of the case. Then return the appeal to the Board, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ Jonathan Hager Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs