Citation Nr: 1804550 Decision Date: 01/24/18 Archive Date: 02/05/18 DOCKET NO. 14-20 054 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for diabetes mellitus, type II, to include as secondary to Agent Orange. 2. Entitlement to service connection for neuropathy of the upper extremities, to include as secondary to diabetes mellitus, type II, and/or Agent Orange. 3. Entitlement to service connection for neuropathy of the lower extremities, to include as secondary to diabetes mellitus, type II, and/or Agent Orange. 4. Entitlement to service connection for obstructive sleep apnea, to include as secondary to an acquired psychiatric disorder. 5. Entitlement to service connection for hypertension, to include as secondary to Agent Orange. 6. Entitlement to service connection for erectile dysfunction, to include as secondary to diabetes mellitus, type II, neuropathy, and/or Agent Orange. 7. Entitlement to service connection for a scar on abdomen. 8. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD), dysthymia, generalized anxiety disorder, and social phobia. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his wife and cousin ATTORNEY FOR THE BOARD S. Hurley, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1966 to February 1970. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision of a Department of Veterans Affairs Regional Office (RO), which, continued its previous denial of service connection for diabetes and neuropathy of the bilateral upper and lower extremities and denied service connection for erectile dysfunction, hypertension, dysthymia (claimed as PTSD), scar on abdomen, and sleep apnea. The Veteran, his wife, and cousin, testified before the undersigned Veterans Law Judge (VLJ) in January 2017. A copy of the transcript has been reviewed and associated with the claims file. The Board notes that the United States Court of Appeals for Veterans Claims (Court) has held that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. See Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009) (stating that what constitutes a claim cannot be limited by a lay veteran's assertion of his condition, but must be construed based on the reasonable expectations of the non-expert claimant and the evidence developed in processing the claim). Therefore, the Board construes the Veteran's claim of service connection for PTSD as encompassing entitlement to service connection for the additional psychiatric diagnoses raised by the record, to include dysthymia, generalized anxiety disorder, and social phobia. Generally, where a claim has been finally adjudicated, a claimant must present new and material evidence in order to reopen the previously denied claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). However, when VA receives relevant service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim. 38 C.F.R. § 3.156(c)(1) (2015). The last prior denial for service connection for diabetes and neuropathy was in an October 2009 rating decision issued by the RO. At the time of the October 2009 rating decision, all of the Veteran's military personnel records were not associated with the claims file. Additional, relevant military personnel records have been added to the record since the last prior decision. As such, the Board will reconsider the claim of service connection for diabetes and neuropathy on a de novo basis, without the need for new and material evidence. The issues of entitlement to service connection for neuropathy of the bilateral upper extremities, obstructive sleep apnea, hypertension, erectile dysfunction, and scar on abdomen 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 currently has diabetes mellitus, type II, which is presumed to be related to exposure to herbicide agents during his active military service in Thailand. 2. The Veteran's neuropathy of his lower extremities is proximately due to or the result of his service-connected diabetes mellitus, type II. 3. The Veteran has been diagnosed with PTSD which is due to the stressful circumstances of his active service. CONCLUSIONS OF LAW 1. The criteria for service connection for diabetes mellitus, type II, have been met. 38 U.S.C. §§ 1110, 1116, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). 2. The criteria for service connection for neuropathy of the lower extremities, to include as secondary to service connected diabetes mellitus, type II, have been met. 38 U.S.C. §§ 1110, 1116, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310(a) (2017). 3. The criteria for service connection for an acquired psychiatric disability, including PTSD, have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304(f) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist In this decision, the Board grants entitlement to service connection for diabetes mellitus, type II, neuropathy of the lower extremities, and PTSD. As this represents a complete grant of relief for the claims adjudicated herein, no discussion of VA's duty to notify or assist is necessary. Legal Criteria Service connection will be granted for a disability resulting from an injury or disease contracted in the line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in the line of duty, in the active military, naval, or air service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303(a) (2017). Service connection requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Consistent with this framework, service connection is warranted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Secondary service connection may be granted for a disability, which is proximately due to, the result of, or aggravated by, an established service connected disorder. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App 439, 449 (1995). Service connection for PTSD generally requires: (1) medical evidence diagnosing the condition in accordance with applicable criteria; (2) a link, established by medical evidence, between current symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f); Anglin v. West, 11 Vet. App. 361, 367 (1998). The Veteran has claimed exposure to herbicides while stationed in Thailand. VA procedures for verifying exposure to herbicides in Thailand during the Vietnam Era are detailed in the VBA Adjudication Manual, M21-1, IV.ii.2.C. VA has determined that there was significant use of herbicides on the fenced-in perimeters of military bases in Thailand intended to eliminate vegetation and ground cover for base security purposes as evidenced in a declassified Vietnam era Department of Defense document titled "Project CHECO Southeast Asia Report: Base Defense in Thailand." Special consideration of herbicide exposure on a facts-found or direct basis should be extended to those Veterans whose duties placed them on or near the perimeters of Thailand military bases. This allows for presumptive service connection of the diseases associated with herbicide exposure. The majority of troops in Thailand during the Vietnam Era were stationed at the Royal Thai Air Force Bases of U-Tapao, Ubon, Nakhon Phanom, Udorn, Takhli, Korat, and Don Muang. If a veteran served on one of these air bases as a security policeman, security patrol dog handler, member of a security police squadron, or otherwise served near the air base perimeter, as shown by MOS (military occupational specialty), performance evaluations, or other credible evidence, then herbicide exposure should be acknowledged on a facts-found or direct basis. However, this applies only during the Vietnam Era, from February 28, 1961, to May 7, 1975. See M21-1, M21-1, IV.ii.1.H.5.b. In adjudicating these claims, the Board must assess the competence and credibility of the Veteran. Washington v. Nicholson, 19 Vet. App. 362 (2005). Lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (lay person competent to testify to pain and visible flatness of his feet). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. I. Diabetes Mellitus, Type II, and Neuropathy The Veteran has been diagnosed with diabetes mellitus, type II, and asserts it was incurred in service due to Agent Orange exposure while stationed in Thailand. A review of the Veteran's military personnel records reveals that he was stationed in Korat, Thailand, from May 1967 to May 1968. His performance evaluation report for that time period demonstrates that he was a phase inspection team member and participated in all facets of the phase inspection concept on the F-105 aircraft. His DD Form 214 indicates that his military occupational specialty was an aircraft maintenance specialist. The Veteran testified at the hearing in January 2017 and indicated that he worked on the flight line daily as a jet mechanic crew chief in Korat. He stated that the runway on the Korat air base was in close proximity to the perimeter. The Board finds that the Veteran is competent to report service near the perimeter of the base while stationed in Thailand. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Absent evidence to the contrary, the Board also finds such statements to be credible. Furthermore, the Veteran submitted a statement by [redacted], a retired Major in the US Army, which was dated in April 2014. Mr. [redacted] attached a photograph and indicated that the runway at the Korat air base abutted the perimeter of the base. Furthermore, a report was submitted by L. Westin titled "Vegetation Control and other uses of Herbicides and Toxic Chemicals at Korat Royal Thai Air Force Base from 1967 to 1972," which was dated May 23, 2011, and last updated April 22, 2013 (herein after "Herbicide Report"). This Herbicide Report attached a photograph (Photo Image 5) taken of the Korat air base in late 1967, which revealed the close proximity of the living quarters to the base perimeter. The Board finds that the photographs of the runway at the Korat air base and living quarters reveal that the Veteran both worked and slept in close proximity to the perimeter of the Korat air base. The evidence of record clearly establishes that the Veteran had service at one of the designated Thailand military bases. He also served on active duty for a period of the Vietnam era during which VA has acknowledged that herbicides were used near those air base perimeters in Thailand. The Veteran has confirmed and the evidence reveals that he was near the perimeter of the military base. In light of the above evidence, the Board finds that the Veteran had service in Korat, Thailand, and his duties placed him on the perimeter of the air force base. As such, he is presumed to have been exposed to herbicides. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Post-service treatment records confirm the Veteran's diagnoses of diabetes mellitus, type II. Therefore, service connection is warranted for diabetes mellitus, type II. With respect to the requirement that the disability manifests to a degree of 10 percent disabling as set forth under 38 C.F.R. § 3.307(a)(6)(ii), the Board finds that the evidence is at least in equipoise on this point. Indeed, to achieve a 10 percent rating for diabetes mellitus pursuant to 38 C.F.R. § 4.119, Diagnostic Code 7913, diabetes must be manageable by a restricted diet. Here, a January 2016 VA treatment record recommended that the Veteran limit eating at night with regard to treatment for his diabetes mellitus, type II. Furthermore, the record reveals that the Veteran has been assessed with diabetes mellitus neuropathy of his lower extremities. See, e.g., October 2015 VA treatment report from an attending physician (stating "Neuropathy: presumed diabetic, on neurontin with fair control"). As such, the Board finds that the competent medical evidence supports a finding that the Veteran's neuropathy of the lower extremities is proximately due to or caused by his service connected diabetes mellitus, type II. Accordingly, service connection for the Veteran's neuropathy of his lower extremities is warranted. In sum, resolving all doubt in favor of the Veteran, the weight of the evidence establishes that the Veteran has a diagnosis of diabetes mellitus, type II, and that he had presumed herbicide exposure during service. Furthermore, the record reveals that the Veteran has neuropathy of his lower extremities due to diabetes mellitus, type II. As such, service connection is warranted for diabetes mellitus, type II, and neuropathy of the lower extremities. 38 C.F.R. §§ 3.102, 3.307(a)(6), 3.309(e), 3.310(a). II. Acquired Psychiatric Disorder The Veteran asserts that service connection is warranted for an acquired psychiatric disorder. Specifically, he states that he has PTSD due to watching a pilot die in a crash in November 1967, a munitions bomb explosion in Korat in March 1968 in which two of his colleagues were killed, and dispatching pilots at the air base and having them not return. With regard to the bomb explosion in Korat in March 1968, the Veteran submitted a statement by F.P. dated in April 2013. F.P. stated that he was at the Korat air base in March 1968 and confirmed that two airmen were killed during the munitions bomb explosion and attached a memorial service pamphlet for one of the airmen, which confirmed he was killed in an explosion at the Korat air base in March 1968. Throughout the time period of this claim, the Veteran has been assessed with PTSD, dysthymia, generalized anxiety disorder, and social phobia. A VA examination was performed in September 2013, at which time the examiner assessed the Veteran with dysthymia and opined it was not caused by or a result of the airplane crash. The examiner concluded that the Veteran did not have a diagnosis of PTSD. The Veteran submitted a July 2014 statement by G.T., Ph.D.. Dr. G.T. concluded that the Veteran suffered from PTSD related to his Vietnam War Service. The Veteran relayed the event that occurred in March 1968, in which bunker bombs began exploding. The Veteran jumped into the defensive trenches awaiting further enemy attack. Two airmen were killed in the incident. Dr. G.T. concluded that the Veteran's PTSD was due to the March 1968 bomb dump explosion. After reviewing the evidence, and resolving doubt in favor of the Veteran, the Board finds that service connection for an acquired psychiatric disorder, to include PTSD, is warranted. The record contains differing opinions as to whether the Veteran has been diagnosed with PTSD. In considering the record as a whole, the Board finds it is in at least equipoise regarding the diagnoses of PTSD, dysthymia, generalized anxiety disorder, and social phobia rendered during the period of appeal. All the opinions provided were rendered by medical professionals with the expertise necessary to opine on the question at issue in this case. In addition, the examiners and treating physicians based their diagnoses on clinical findings and the Veteran's medical history. The Board is therefore unable to assign greater probative weight to any of these opinions and thus finds that the first element of service connection is satisfied. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (discussing factors for determining probative value of medical opinions). The record contains written statements from the Veteran detailing several stressful incidents that occurred while serving in Thailand. The Veteran stated that his PTSD stressor included a March 1968 incident, in which he ran into a foxhole because he heard explosions. He was there most of the night. In the morning he found that the storage area where the bombs were kept had blown up. Two airmen were killed in the bombing. This stressor was corroborated by a statement by F.P. dated in April 2013, in which he submitted the memorial pamphlet from one of the airmen who died in the explosion in March 1968. The remaining question, therefore, is whether there is competent medical evidence linking the Veteran's diagnosed psychiatric disorders to his active service, to include the stressor. The Board observes that the September 2013 VA examiner indicated that the Veteran's dysthymia is not related to his active service. However, in a statement dated in July 2014, Dr. G.T. concluded that the Veteran's PTSD was due to the March 1968 bomb dump explosion. Again, for the reasons discussed above, the Board can find no basis upon which to assign greater probative weight to either medical opinion with regard to the psychiatric disabilities diagnosed. However, the Board gives greater weight to Dr. G.T.'s rationale connecting the Veteran's PTSD to the March 1968 bomb explosion. In this regard, although the September 2013 VA examiner acknowledged the March 1968 bomb explosion, she failed to provide a rationale as to why the Veteran's dysthymia was not related to this bomb explosion. Dr. G.T. better considered the record as a whole and provided a detailed rationale as to why the Veteran's PTSD and correlating symptoms were related to this confirmed March 1968 stressor. As set forth above, under the benefit-of-the-doubt rule, for the Veteran to prevail, there need not be a preponderance of the evidence in his favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Given the evidence set forth above, such a conclusion certainly cannot be made in this case. Under these circumstances, the record is sufficient to award service connection for a psychiatric disorder, to include PTSD. See 38 C.F.R. § 3.304(f). ORDER Service connection for diabetes mellitus, type II, is granted. Service connection for neuropathy of the bilateral lower extremities is granted, on the basis that it is proximately due to or caused by his service-connected diabetes mellitus, type II. Service connection or an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is granted REMAND Neuropathy of the Upper Extremities The Veteran filed a claim for neuropathy of the upper extremities and indicated it is due to Agent Orange exposure. As discussed above, the Veteran has been assessed with neuropathy of his lower extremities due to diabetes mellitus. However, the record is unclear if he has a diagnosis of neuropathy of his upper extremities. The Veteran's VA treatment notes reveal that he complained of neuropathy in October 2009, which he described as burning from his elbows to fingers. During the September 2013 VA exam for PTSD, he complained of problems with neuropathy in his feet and hands. During the hearing in January 2017, the Veteran testified that after service he noticed his fingers becoming numb. In September 2015, K.W.J., M.D., filled out an Agent Orange peripheral neuropathy review check list. Dr. K.J. concluded that the Veteran had no in country Vietnam service. Under applicable legal criteria, if a veteran was exposed to an herbicide agent during active military, naval, or air service, certain enumerated diseases shall be service connected if the requirements of 38 U.S.C. § 1116, 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C. § 1113; 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e) (2017). The Board notes that during the course of the claim, there was a change in the law concerning what type of peripheral neuropathy is presumptively service connected based on in-service Agent Orange exposure. Effective September 6, 2013, the provisions of 38 C.F.R. § 3.309 were revised by replacing the term "acute and subacute" peripheral neuropathy with "early-onset" peripheral neuropathy. VA also removed Note 2 to § 3.309(e), which had required that the neuropathy be transient and appear within weeks or months of exposure to an herbicide agent and resolve within two years of the date of onset. Under the amendments, peripheral neuropathy still must become manifest to a degree of 10 percent or more within one year after the date of last exposure to herbicides in order to qualify for the presumption of service connection. 38 C.F.R. § 3.307(a)(6)(ii). However, the peripheral neuropathy no longer needs to be transient. See 78 Fed. Reg. 54763 (Sept. 6, 2013). The Board observes that the Veteran has not been provided a VA examination. Upon remand, the Veteran should be afforded a VA examination to determine the nature and etiology of any neuropathy of the lower extremities, including his claim that it is due to his Agent Orange exposure and/or his service-connected diabetes mellitus, type II. See McLendon v. Nicholson, 20 Vet. App. 79, 81-83 (2006). Hypertension The Veteran has been assessed with hypertension and asserts it is related to his Agent Orange exposure. The Board notes that the Veteran has not been afforded a VA examination with regard to his claim of service connection for hypertension. The Board finds that one should be provide as the evidence shows a current disability and an in-service event (presumed herbicide exposure). McLendon v. Nicholson, 20 Vet. App. 79, 81-83 (2006). The Board also finds that there is an indication of a relationship between these two, as explained next. As discussed above, Agent Orange exposure has been established on a facts found basis. The Board notes that the Veteran has not offered any scientific evidence or testimony as to why the hypertension is related to Agent Orange exposure. Although VA has not conceded a relationship between hypertension and Agent Orange, it is significant to note that prior to 2006, the National Academy of Science (NAS) placed hypertension in the "Inadequate or Insufficient Evidence" category. However, in its 2006 Update, NAS elevated hypertension to the "Limited or Suggestive Evidence" category. Update 2012 provides the history of NAS changing the categorizing of hypertension beginning in its 2006 Update and subsequent Updates. See Fed. Reg. 20, 308 (Apr. 11, 2014). The NAS updates are published in the Federal Register by VA, and thus VA is on notice as to the information contained therein. Update 2012 notes that NAS has defined this category of limited or suggestive evidence to mean the "evidence suggests an association between exposure to herbicides and the outcome, but a firm conclusion is limited because chance, bias, and confounding could not be ruled out with confidence." Id. at 20, 309. The suggestive evidence of an association is sufficient to establish an "indication" that the current disability "may be related" to herbicide exposure during service, as contemplated by 38 U.S.C. § 5103A(d)(2)(B) (2012). In this regard, the Court has described this threshold of the statute as being low. McLendon, 20 Vet. App. at 83. Given that no medical opinion has been offered as to whether the Veteran's hypertension is related to his military service, including Agent Orange exposure, the Board finds that a remand for a VA examination is warranted. Obstructive Sleep Apnea The Veteran has been assessed with obstructive sleep apnea and asserts that it is due to his service-connected acquired psychiatric disability. The Board notes that the Veteran has not been afforded a VA examination with regard to his claim of service connection for obstructive sleep apnea. The Board finds that one should be provided given that there is a current disability and an indication it may be related to his service-connected disability, to include the now service-connected psychiatric disability. McLendon, 20 Vet. App. at 81-83. Erectile Dysfunction The Veteran asserts that he has erectile dysfunction due to diabetes mellitus, type II, neuropathy, and/or exposure to Agent Orange. The Board notes that the record is unclear if the Veteran has a current erectile dysfunction disability. A VA treatment record dated in April 2013 indicates that the Veteran attended diabetes class education and a preventing complication was listed as erectile dysfunction. The Board notes that the Veteran has not been afforded a VA examination with regard to his claim of service connection for erectile disability. Given that there is an indication that the Veteran may have a current erectile dysfunction disability that is related to a service-connected disability, the Board finds that a VA examination is warranted. McLendon, 20 Vet. App.at 81-83. Scar on Abdomen The Veteran asserts that he has a scar over his abdomen, which is related to an appendix operation while he was in service. His January 1970 separation examination reveals that he had a four inch lower quadrant abdominal surgical scar. The Veteran's VA treatment records indicate that he has old scar tissue underneath his abdominal pannus, bilaterally, near the groin. The Board notes that the Veteran has not been afforded a VA examination with regard to his claim of service connection for a scar over his abdomen. The Board finds that one should be provided given that there is a current disability and an indication it may be related to service. McLendon, 20 Vet. App. at 81-83. Accordingly, the case is REMANDED for the following actions: 1. Schedule the Veteran for a VA medical examination to determine the nature and etiology of any neuropathy and/or bilateral upper extremity disability. The claims folder must be provided to the examiner for review in connection with the examination. Review of the claims file should be confirmed in the examination report. All necessary studies, tests, and evaluations deemed necessary by the examiner should be performed with the examination. The examiner is to identify all neuropathy-related disabilities of the upper extremities found since the filing of the claim in June 2012. Thereafter, the examiner should respond to the following questions: a. Does the Veteran have a current neuropathy related disability of the upper extremities? If so, please identify. b. If the response to (a) is yes, is it at least as likely as not (a 50 percent or greater probability) that the diagnosed neuropathy related disability of the upper extremities manifested during the Veteran's period of active service; manifested to a compensable degree within one year of his separation of service; or is otherwise causally related to his active service or any incident therein, including his presumed exposure to Agent Orange? c. If the response to (a) is yes, and the Veteran's diagnosed neuropathy related disability of the upper extremities is not related to his period of active service, is it at least as likely as not (probability of at least 50 percent) that the Veteran's current upper extremity disability is (1) caused by his service connected diabetes mellitus, type II, and/or (2) aggravated (chronically worsened) by his service-connected diabetes mellitus, type II. If aggravation is found for the neuropathy related disability of the upper extremities, is there medical evidence created prior to the aggravation or between the aggravation and current level of disability that shows a baseline of the neuropathy prior to aggravation? The examiner must provide a comprehensive rationale for each opinion provided. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of his hypertension. The claims file, including this remand, is to be reviewed by the examiner to become familiar with the pertinent medical history and such review should be noted in the examination report. The examiner should provide the following opinion: is it at least as likely as not (probability of at least 50 percent) that hypertension had its onset in and/or is otherwise etiologically related to the Veteran's period of active military service, to include exposure to herbicide agents? The examiner must provide a comprehensive rationale for each opinion provided. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of his obstructive sleep apnea. The claims file, including this remand, is to be reviewed by the examiner to become familiar with the pertinent medical history of his obstructive sleep apnea and this review should be noted in the examination report. The examiner should provide the following opinions: A. Is it at least as likely as not (probability of at least 50 percent) that the Veteran's current obstructive sleep apnea is caused by his service-connected acquired psychiatric disorder? B. Is it at least as likely as not (probability of at least 50 percent) that the Veteran's obstructive sleep apnea has been aggravated (chronically worsened) by his service connected acquired psychiatric disorder? If aggravation is found is there medical evidence created prior to the aggravation or between the aggravation and current level of disability that shows a baseline of the obstructive sleep apnea prior to aggravation? c. If the Veteran's obstructive sleep apnea is not caused or aggravated by the Veteran's service-connected acquired psychiatric disorder, is it at least as likely as not (probability of at least 50 percent) that the obstructive sleep apnea is etiologically related to the Veteran's period of active service? The examiner must provide a comprehensive rationale for each opinion provided. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of any erectile dysfunction disorder. The claims file, including this remand, is to be reviewed by the examiner to become familiar with the pertinent medical history and this review should be noted in the examination report. The examiner should provide the following opinions: a. Does the Veteran have a current erectile dysfunction disability? Please note a current disability is defined as a disability since, or proximately to, the filing of this claim in June 2012. If the answer to (a) is yes, please respond to the following: b. Is it at least as likely as not (probability of at least 50 percent) that the Veteran's current erectile dysfunction is caused by his service connected diabetes mellitus, type II, and/or neuropathy? b. Is it at least as likely as not (probability of at least 50 percent) that the Veteran's current erectile dysfunction has been aggravated (chronically worsened) by his service connected diabetes mellitus, type II, and/or neuropathy? If aggravation is found is there medical evidence created prior to the aggravation or between the aggravation and current level of disability that shows a baseline of the erectile dysfunction prior to aggravation? c. If the Veteran's erectile dysfunction is not caused or aggravated by the Veteran's service connected diabetes mellitus, type II, and/or neuropathy, is it at least as likely as not (probability of at least 50 percent) that the erectile dysfunction is etiologically related to the Veteran's period of active service, including conceded exposure to Agent Orange? The examiner must provide a comprehensive rationale for each opinion provided. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. 5. Schedule the Veteran for a VA examination to determine the nature and etiology of the scar over his abdomen. The claims file, including this remand, is to be reviewed by the examiner to become familiar with the pertinent medical history and such review should be noted in the examination report. The examiner should provide the following opinion: is it at least as likely as not (probability of at least 50 percent) that current abdomen scar had its onset in and/or is otherwise etiologically related to the Veteran's period of active military service, including the appendix surgery in service. The examiner must provide a comprehensive rationale for each opinion provided. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. 6. Thereafter, readjudicate the issues on appeal. If the determination remains unfavorable to the Veteran, he and his representative should be furnished a supplemental statement of the case which addresses all evidence associated with the claims file since the last statement of the case. The Veteran and his representative should be afforded the applicable time period in which to respond. 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 is 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 (2012). ______________________________________________ Paul Sorisio Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs