Citation Nr: 1824948 Decision Date: 04/25/18 Archive Date: 05/03/18 DOCKET NO. 03-08 554A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to service connection for diabetes mellitus, to include due to exposure to herbicides. 2. Entitlement to service connection for loss of use of penile functionality, to include due to exposure to herbicides. 3. Entitlement to service connection for a cardiac disease, to include due to exposure to herbicides. 4. Entitlement to service connection for an acquired psychiatric disorder other than PTSD. 5. Entitlement to service connection for hepatocellular carcinoma, to include due to exposure to herbicides. 6. Whether new and material evidence to reopen a claim for service connection for posttraumatic stress disorder (PTSD) has been received. 7. Entitlement to a total rating based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Appellant represented by: California Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Brandon A. Williams, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1959 to August 1963. This appeal to the Board of Veterans' Appeals (Board) arose from a June 2002 rating decision in which the RO in Honolulu, Hawaii, inter alia, denied service connection for diabetes mellitus. The Veteran filed a notice of disagreement (NOD) in September 2002. The RO issued a statement of the case (SOC) in February 2003, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in April 2003. Jurisdiction over the Veteran's claim was subsequently transferred to the RO in San Diego, California. In December 2005, the Veteran testified during a hearing before a Decision Review Officer (DRO) in connection with the claim for service connection for diabetes mellitus; a transcript of the hearing is of record. In October 2007 and February 2010, the Board remanded the issue of entitlement to service connection for diabetes mellitus to the agency of original jurisdiction (AOJ) for further development. After accomplishing further action, the AOJ continued to deny the claim for service connection for diabetes mellitus (as reflected in October 2008, October 2009, and March 2011 supplemental SOCs (SSOCs)) and returned this matter to the Board for further consideration. In a March 2011 rating decision, the RO denied service connection for a cardiac disease (identified as AV block, status post cardiac arrest, status post pacemaker implantation), bipolar disorder, and hepatocellular carcinoma. The RO also denied service connection for loss of use of penile functionality by way of a November 2011 rating decision. In January 2012, the Veteran filed an NOD as to all issues decided in the March and November 2011 rating decisions. The RO issued an SOC in February 2013, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in March 2013. Informal hearing conferences with a DRO were conducted in January and February 2013; the reports of these conferences are of record. In a February 2013 rating decision, the RO denied a TDIU. The Veteran filed an NOD in March 2013. The RO issued an SOC in July 2013, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in September 2013. In June 2015, the Board recharacterized the claim adjudicated one for service connection for a psychiatric disorder as actually encompassing the separate matters of (1) whether new and material evidence to reopen a claim for service connection for PTSD had been received and (2) entitlement to service connection for a psychiatric disorder other than PTSD. The Board remanded these matters, as well as the claims for service connection for diabetes mellitus, loss of use of penile functionality, a cardiac disease, and hepatocellular carcinoma, and the claim for a TDIU, to the AOJ in order to schedule the Veteran for a Board hearing before a Veterans Law Judge (VLJ). The issues were again remanded in May 2017 in order to schedule the Veteran for a Board hearing before a VLJ. In October 2017, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of this hearing is associated with the claims folder. These matters have all been returned to the Board for further consideration. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (West 2014). The issues of entitlement to service connection for loss of use of penile functionality, entitlement to service connection for cardiac disease, entitlement to service connection for an acquired psychiatric disorder, entitlement to service connection for PTSD, and TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran served within Thailand, along the Mekong River from at least May 1962 until June 1962. 2. The Veteran has been diagnosed with type II diabetes mellitus that is compensably disabling. 3. The Veteran's hepatocellular carcinoma is related to active service. 4. The claim for entitlement to service connection for PTSD was previously denied in an October 1996 rating decision, the Veteran did not appeal the decision. 5. Some of the evidence submitted subsequent to the October 1996 rating decision is not cumulative or redundant, relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim for entitlement to service connection for PTSD. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for type II diabetes mellitus have been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 2. The criteria for service connection for hepatocellular carcinoma, to include as due herbicide exposure have been met. 38 U.S.C. §§ 1101, 1110, 1154, 5107 (West 2014); 38 C.F.R. § 3.303, 3.304 (2017). 3. The unappealed October 1996 rating decision which denied service connection for PTSD is final. 38 U.S.C. § 5108, 7105 (West 2014); 38 C.F.R. § 3.156 (a), 3.104(a), 20.302, 20.1103 (2017). 4. Evidence received since the October 1996 RO decision that denied entitlement to service connection for PTSD is new and material; the claim is reopened. 38 U.S.C. § 1154 (a), 5108, 7105 (West 2014); 38 C.F.R. § 3.156, 20.302, 20.1103 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. § 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. § 3.102, 3.156(a), 3.159, 3.326 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Entitlement to service connection for diabetes mellitus, to include due to exposure to herbicides. Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). For some "chronic diseases," presumptive service connection is available. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With "chronic disease" shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303 (b). For the showing of a 'chronic disease' in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303 (b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic disease' became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The term "chronic disease," whether as shown during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309 (a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. Feb. 21, 2013). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of such Veteran's service as shown by such Veteran's service record, the official history of each organization in which such Veteran served, such Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C. § 1154 (a) (West 2014). Presumptive service connection - herbicide exposure VA regulations provide that certain diseases associated with exposure to herbicide agents may be presumed to have been incurred in service even if there is no evidence of the disease in service, provided the requirements of 38 C.F.R. § 3.307 (a)(6) are met. 38 C.F.R. § 3.309 (e) (2015). A Veteran who, during active service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307 (a). The last date on which such a Veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975. The term "herbicide agent" means a chemical in an herbicide, including Agent Orange, used in support of the United States and allied military operations in the Republic of Vietnam during the Vietnam era. If a Veteran was exposed to an herbicide agent during active service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307 (a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307 (d) are also satisfied: Chloracne or other acne form disease consistent with chloracne; Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes); Hodgkin's disease; chronic lymphocytic leukemia; B cell leukemia, Parkinson's disease, multiple myeloma; non-Hodgkin's lymphoma; early-onset peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx or trachea); soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma); and ischemic heart disease, (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), shall be service-connected if the requirements of 38 C.F.R. § 3.307 (a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307 (d) are also satisfied. 38 C.F.R. § 3.309 (e). The diseases listed at 38 C.F.R. § 3.309 (e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the Veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). While all Veterans who served in the Republic of Vietnam during the Vietnam Era are presumed to have been exposed to an herbicide agent, the Veteran claims he is entitled to the presumption of herbicide exposure because he was stationed in Thailand and engaged in patrols along the Mekong River, to include at least one day in Vietnam. 38 U.S.C. § 1116 (f) (West 2014); 38 C.F.R. § 3.307, 3.313 (2017). The Board notes that "Service in Vietnam" for purposes of applying the herbicide presumption includes service in the waters offshore or service in other locations if the conditions of service involved duty or visitation to Vietnam between January 9, 1962 and May 7, 1975. 38 U.S.C. § 1116 (a)(3) (West 2014); 38 C.F.R. §§ 3.307 (a)(6)(iii), 3.313(a) (2017). VA has validly interpreted the "service in Vietnam" language of the statute and regulation as requiring that a Veteran must have actually been present at some point on the landmass or the inland waters of Vietnam during the Vietnam conflict. See Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008). During the course of the appeal, the United States Court of Appeals for Veterans Claims (Court) decided Gray v. McDonald, 27 Vet. App. 313 (2015). The Court directed VA to reevaluate its definition of inland waterways. In response, VA compiled a list of ships that operated in the inland waterways of Vietnam. See http://www.publichealth.va.gov/exposures/agentorange/shiplist/index.asp. The list contains five categories of ships that operated on the waters of Vietnam. A ship is placed on this list when documentary evidence shows that it fits into a particular category. The required evidence can come from an official ship history, deck logs, cruise books, Captain's letters, or similar documents. A specific ship may be listed in more than one category, based on its activities. Evidence requirements for the presumption of herbicide exposure may vary depending on what dates the Veteran was aboard and what ship activity occurred on those dates. Ship categories include, but are not limited to "Ships operating temporarily on Vietnam's inland waterways." Id. The "Ships operating temporarily on Vietnam's inland waterways" category includes large ocean-going ships that operated primarily on Vietnam's offshore waters for gunfire support of ground operations and interdiction of enemy vessels travelling along coastal waters. It also includes ships supplying and supporting these operations. Examples of such vessels include destroyers, cruisers, and cargo ships. The deep offshore waters are often referred to as "blue waters" and naval vessels operating on them are referred to as the Blue Water Navy. Ships in this category entered Vietnam's inland waterways temporarily as part of their gunfire, interdiction, or support missions. VA has agreed that all Veterans who served aboard these vessels at the time of entry into Vietnam's inland waterways are eligible for the presumption of herbicide exposure. In October 2007, the Board requested the Veteran's unit histories and lessons learned from the Federal custodian of records of the United States Marine Corps. In January 2008, the RO received a response from the National Personnel Records Center that unit histories, including staff daily journals, after action reports, and operational reports and lessons learned were not maintained there. The record contains declassified documents from May and June 1962 that show that the Veteran's unit was stationed in Thailand and that it conducted daily patrols along the Mekong River from Laos to the Thai-Cambodian border. As noted above, VA has conceded herbicide exposure for Veteran who was aboard or operated within Vietnam's inland waterways. Notably, VA list the Mekong River within the inland waterways provided the presumption of herbicide exposure. Therefore, based on the above, and resolving all reasonable doubt in his favor, the Board finds that the Veteran is presumed to have been exposed to herbicide agents during service. Private medical treatment reports that the Veteran has diagnosed with and treated for diabetes. (See private treatment medical records). As the Veteran's diabetes is treated with an oral hypoglycemic agent and continuous medication, the Veteran's diabetes has been manifested to a compensable level for VA purposes. See 38 C.F.R. § 4.119, Diagnostic Code 7913 (2017). As noted above, diabetes mellitus is presumed to be due to exposure to certain herbicide agents, if it has become manifest to a degree of 10 percent or more at any time after service. See 38 C.F.R. §§ 3.307, 3.309(e). Therefore, service connection for diabetes mellitus is warranted. 38 U.S.C. § 5107 (b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for hepatocellular carcinoma, to include due to exposure to herbicides. The Veteran asserts that he has hepatocellular carcinoma that is related to his presumed herbicide exposure. Importantly, while the Veteran was exposed to an herbicide agent during his service within Thailand; hepatocellular carcinoma is not a disease listed for presumptive service connection. 38 C.F.R. § 3.309 (e). However, the Veteran may still be entitled to service connection for hepatocellular carcinoma on a direct basis. Here, private treatment records reflect the Veteran has been diagnosed and treated for hepatocellular carcinoma. As such an essential element has been met. As explained previously, the Veteran is found to have been exposed to herbicides during his military service along the Mekong River. As such, the Board finds that an element of a service connection claim, injury in service, has been met (i.e. exposure to agent orange). Generally, a third element for service connection is competent credible evidence of a nexus between the current disability and the in-service disease or injury, or, in some cases, continuity of symptoms. In a September 2013 letter to the VA, the Veteran's physician opined that if the Veteran was exposed to Agent Orange this could be a causal effect to his hepatocellular carcinoma. The physician noted a controlled study which suggested that Veterans who are presumed to have been exposed to Agent Orange (herbicides) was associated with an increased risk of hepatocellular carcinoma. Based on the above, the Board finds that the Veteran's hepatocellular carcinoma is casually related to the Veteran's active service. In light of the Veteran's confirmed in-service incurrence, the objective clinical medical evidence, and his credible and competent statements in support of the claim, the Board finds that the evidence is at least in equipoise regarding service connection for hepatocellular carcinoma and will resolve reasonable doubt in favor of the Veteran. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). All the elements necessary for establishing service connection are met and the Veteran's claim for service connection for hepatocellular carcinoma is granted. Whether new and material evidence to reopen a claim for service connection for PTSD has been received Legal criteria In general, RO decisions that are not timely appealed are final. See 38 U.S.C. § 7105 (West 2014); 38 C.F.R. § 20.200 (2017). An exception to this rule is 38 U.S.C.A. § 5108 , which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. The Board must consider the question of whether new and material evidence has been received because it goes to the Board's jurisdiction to reach the underlying claim and adjudicate the claim de novo. See Jackson v Principi, 265 F.3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). "New" evidence is existing evidence not previously submitted to agency decision makers. "Material" evidence is existing 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 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 determining whether evidence is new and material, the "credibility of the evidence is to be presumed." Justus v. Principi, 3 Vet. App. 510, 513 (1992). In order for evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material. If the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. See Smith v. West, 12 Vet. App. 312, 314 (1999). If it is determined that new and material evidence has been submitted, the claim must be reopened. VA may then proceed to evaluate the merits of the claim on the basis of all evidence of record, but only after ensuring that the duty to assist the appellant in developing the facts necessary for the claim has been satisfied. See Elkins v. West, 12 Vet. App. 209 (1999). Historically, the Veteran's claim for entitlement to service connection for PTSD was previously denied by the RO in October 1996. The Veteran did not appeal the October 1996 decision and it became final. The Veteran requested that his claim be reopened and was subsequently denied in a June 2002 RO decision. Evidence of record at time of last final denial At the time of the October 1996 RO denial, the evidence of record consisted of the Veteran's DD 214, STRs, medical records, and the Veteran's lay statements. Evidence of record since the last final denial The evidence received since the last final denial includes additional treatment medical records in regard to the Veteran's PTSD, to include a January 2013 VA medical examination. Old and new evidence of record considered as a whole The Board finds that some of the additional evidence raises a possibility of substantiating the claim for entitlement to service connection for PTSD. In this regard, the Board is mindful of the low threshold for reopening a previously denied claim. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). The January 2013 VA medical examination was not within the claims file at the time of the October 1996 RO decision. The January 2013 VA medical examination goes to the basis of the Veteran's claim for entitlement to service connection for PTSD. Thus, the Board finds the medical records and Veteran statements in support of the claim obtained after the October 1996 RO decision to be new and material. Accordingly, the Board concludes that evidence has been received which is new and material, and the claim for service connection for PTSD, is reopened. ORDER Entitlement to service connection for diabetes mellitus is granted. Entitlement to service connection for hepatocellular carcinoma is granted. New and material evidence has been received to reopen a previously denied claim of service connection for PTSD, and to that extent, the claim is granted. REMAND PTSD and any other acquired psychiatric disorder Having reopened the Veteran's PTSD claim, the Board must now determine whether the reopened claim of entitlement to service connection for PTSD may be granted on the merits, de novo. Here, the Board finds that a VA examination and opinion is necessary. The claims folder reflects the Veteran with a diagnosis and treatment for PTSD and depression among others. The Board finds that an examination assessing the Veteran's current mental condition is necessary prior to adjudicating the issue on appeal. Entitlement to service connection for loss of use of penile functionality, to include due to exposure to herbicides. In regard to the Veteran's for entitlement to service connection for loss of use of penile functionality, the Board finds that a remand is necessary. The claims file does not reflect that the Veteran has been provided a VA medical examination or medical opinion in regard to his issues for service connection. VA's duty to assist requires it to provide an adequate medical examination and/or obtain a medical opinion if the evidence is not sufficient to decide the claim. However; in order for the duty to assist to be triggered, the following must be present: (A) competent lay or medical evidence of a current disability, persistent, or recurrent symptoms of a disability, (B) evidence establishing the Veteran suffered an event, injury, or disease or symptoms of a disease, and (C) evidence indicating that the claimed disability or symptoms may be associated with the established event, injury, or disease in service. 38 C.F.R. § 3.159 (c)(4)(i). The Board finds that the requirements have been met in order to trigger the VA's duty to assist for the reasons stated below. In this case, without adequate medical examinations and medical opinions in regard to the Veteran's claimed conditions, the Board finds the current evidence to be insufficient to decide the claims. Therefore, a VA medical examination and medical opinion are required by VA's duty to assist the Veteran in developing evidence to substantiate his claims to service connection. Additionally, the Veteran has asserted that his penile functionality loss may be attributable to his now service-connected diabetes mellitus. As such, an opinion discussing whether the Veteran's alleged penile functionality loss is related to, or aggravated by, his service connected disabilities. Entitlement to service connection for a cardiac disease, to include due to exposure to herbicides. In regard to the Veteran's for entitlement to service connection for cardiac disease, the Board finds that a remand is necessary. The claims folder reflects that the Veteran has been diagnosed with, and subsequently received treatment for a third degree heart block. However, June 2007 private records note the Veteran with no history heart disease. The Board finds that an examination assessing the Veteran current heart status is necessary prior to adjudication. TDIU The Board has considered the question of whether the Veteran would be prejudiced by considering the appeal for TDIU while remanding the other issues on appeal. Specifically, the Board questions whether the issues are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). As the outcome of the claim on being remanded could have a significant impact on the Veteran's appeal for entitlement to TDIU, the Board finds these matters inextricably intertwined. The Board also notes that an undecided issue "inextricably intertwined" with an issue certified for appeal must be adjudicated prior to appellate review. Thus, the issue for entitlement to TDIU must be remanded. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Request the appellant to identify all medical providers (VA and private) from whom he has received treatment for his claimed disabilities, and complete and return a provided VA Form 21-4142, Authorization and Consent to Release Information, for the identified treatment records, for each medical treatment provider identified. After obtaining completed VA Forms 21-4142, the AOJ should attempt to obtain all identified pertinent medical records and associate them with the claims file. 2. After associating all newly acquired records with the claims file, schedule the Veteran for a VA mental health examination in regard to entitlement to service connection for an acquired psychiatric condition, to include PTSD, with the appropriate clinician. The examiner is requested to furnish an opinion as to whether it is at least as likely as not that the Veteran currently has any acquired psychiatric disorder, to include PTSD and depression related to, or aggravated by, his military service. Any opinion should include a complete rationale. The examiner must explain any conflicting diagnosis and/or treatment with regard to the Veteran's psychiatric condition. 3. Schedule the Veteran for a VA medical examination with the appropriate examiner in regard to entitlement to service connection for loss of use of penile functionality. The examiner is requested to furnish the following opinions: a.) Whether it is at least as likely as not (50 percent or greater) that the Veteran has a penile functionality disorder related to, or aggravated by, his military service, to include due to exposure to herbicides; and b.) Whether it is at least as likely as not that the Veteran has a penile functionality disorder caused or aggravated by his service-connected diabetes mellitus. In providing the opinion, the examiner must provide a full and complete rationale explaining the reasoning for all opinions given. If the examiner is unable to provide the opinion requested, then he or she must state so and provide an explanation as to why an opinion cannot be given. 4. Schedule the Veteran for a VA medical examination with the appropriate examiner, in regard to entitlement to service connection for a cardiac disease. The examiner is requested to furnish an opinion as to whether it is at least as likely as not (50 percent or greater) that the Veteran has a heart disorder related to, or aggravated by, his military service, to include due to exposure to herbicides. Importantly, the Veteran is found to have been exposed to herbicides during his active service. As such, the physician is requested to note whether the Veteran has an ischemic heart disease. 5. After completion of the above requested development, and any other development deemed necessary, readjudicate the claims on appeal. If the benefits sought on appeal remain denied, furnish the Veteran and his representative a supplemental statement of the case, and afford them the opportunity to respond before the claims file is returned to the Board for further appellate consideration. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim 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. §§ 5109B, 7112 (West 2014). ______________________________________________ M. H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs