Citation Nr: 18139631
Decision Date: 09/28/18	Archive Date: 09/28/18

DOCKET NO. 15-04 085A
 DATE:	September 28, 2018
ORDER
As new and material evidence has been received, the claim for service connection for Type II diabetes mellitus claimed as the result of herbicide agent exposure is reopened.  
Service connection for Type II diabetes mellitus claimed as the result of herbicide agent exposure is granted.  
As new and material evidence has been received, the claim for service connection for diabetic peripheral neuropathy is reopened.  
Service connection for diabetic peripheral neuropathy of the upper extremities and the lower extremities is granted.  
As new and material evidence has been received, the claim for service connection for a heart disorder is reopened.  
Service connection for ischemic heart disease to include coronary artery disease and coronary artery bypass graft (CABG) residuals is granted.  
As new and material evidence has been received, the claim for service connection for hypertension is reopened.  
As new and material evidence has been received, the claim for service connection for a lung disorder is reopened.  
Service connection for a right ankle disorder is denied.  
Service connection for a left ankle disorder is denied.
Service connection for an ulcer disorder is denied.  
An effective dated prior to March 27, 2013, for the award of service connection for posttraumatic stress disorder (PTSD) is denied.  
REMANDED
The issue of service connection for hypertension is remanded.  
The issue of service connection for cerebrovascular accident residuals is remanded.  
The issue of service connection for a recurrent lung disorder is remanded.  
The issue of service connection for a recurrent sleep disorder to include insomnia is remanded.  
The issue of an initial rating in excess of 70 percent for the service connected posttraumatic stress disorder (PTSD) is remanded.  
The issue of a rating in excess of 10 percent for the service connected left ear suppurative otitis media with cholesteatoma is remanded.  
The issue of a rating in excess of 10 percent for the service connected bilateral high frequency hearing loss is remanded.  
The issue of a rating in excess of 10 percent for tinnitus is remanded.
The issue of entitlement to a total rating for compensation purposes based on individual unemployability due to service connected disabilities (TDIU) is remanded.  
FINDINGS OF FACT
1. A June 2009 Department of Veterans Affairs (VA) rating decision denied service connection for Type II diabetes mellitus claimed as the result of herbicide agent exposure.  The Veteran did not submit a timely notice of disagreement and the June 2009 rating decision is final.  
2. The additional evidence received since the June 2009 rating decision is new and material.  
3. The Veteran is presumed to have been exposed to herbicide agents at Udorn Royal Thai Air Force Base (RTAFB), Thailand.  
4. Type II diabetes mellitus was diagnosed following active service.  
5. Service connection is in effect for PTSD, left ear suppurative otitis media with cholesteatoma, bilateral high frequency hearing loss, and tinnitus.  Service connection has been granted in this decision for Type II diabetes mellitus.  
6. A June 2009 VA rating decision denied service connection for diabetic peripheral neuropathy.  The Veteran did not submit a timely notice of disagreement and the June 2009 rating decision is final.  
7. The additional evidence received since the June 2009 rating decision is new and material.  
8. Diabetic peripheral neuropathy of the upper extremities and lower extremities was manifested secondary to the service connected Type II diabetes mellitus.  
9. A June 2009 VA rating decision denied service connection for a heart disorder.  The Veteran did not submit a timely notice of disagreement and the June 2009 rating decision is final. 
10. The additional evidence received since the June 2009 rating decision is new and material.  
11. Coronary artery disease with CABG residuals was diagnosed following active service.  
12. A June 2009 VA rating decision denied service connection for hypertension.  The Veteran did not submit a timely notice of disagreement and the June 2009 rating decision is final.
13. The additional evidence received since the June 2009 rating decision is new and material.
14. A June 2009 VA rating decision denied service connection for a lung disorder.  The Veteran did not submit a timely notice of disagreement and the June 2009 rating decision is final.
15. The additional evidence received since the June 2009 rating decision is new and material.
16. A recurrent right ankle disorder was not shown during active service or at any time thereafter.  
17. A recurrent left ankle disorder was not shown during active service or at any time thereafter.  
18. A recurrent ulcer disorder was not shown during active service or at any time thereafter.  
19. PTSD originated during active service.  
20. The Veteran’s March 2013 claim for service connection for PTSD was received by the Department of Veterans Affairs (VA) on March 27, 2013.  
CONCLUSIONS OF LAW
1. The June 2009 VA rating decision which denied service connection for Type II diabetes mellitus claimed as the result of herbicide agent exposure is final.  38 U.S.C. § 7105; 38 C.F.R. § 20.1103.  
2. New and material evidence to reopen the claim for service connection for Type II diabetes mellitus has been presented.  38 U.S.C. § 5108; 38 C.F.R. § 3.156.  
3. The criteria for service connection for Type II diabetes mellitus presumed due to herbicide agent exposure have been met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309; VA Adjudication Procedures Manual, M21-1MR, Part IV.ii.2.C.10.q.  
4. The June 2009 VA rating decision which denied service connection for diabetic peripheral neuropathy is final.  38 U.S.C. § 7105; 38 C.F.R. § 20.1103.  
5. New and material evidence to reopen the claim for service connection for diabetic peripheral neuropathy has been presented.  38 U.S.C. § 5108; 38 C.F.R. § 3.156.  
6. The criteria for service connection for diabetic peripheral neuropathy of the upper extremities and the lower extremities have been met. 38 U.S.C. §§ 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.310(a).  
7. The June 2009 VA rating decision which denied service connection for heart disorder is final.  38 U.S.C. § 7105; 38 C.F.R. § 20.1103.  
8. New and material evidence to reopen the claim for service connection for a heart disorder has been presented.  38 U.S.C. § 5108; 38 C.F.R. § 3.156.  
9. The criteria for service connection for ischemic heart disease to include coronary artery disease and CABG residuals presumed due to herbicide agent 
exposure have been met.  38 U.S.C. §§ 1110, 1112, 1113, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309; VA Adjudication Procedures Manual, M21-1MR, Part IV.ii.2.C.10.q.  
10. The June 2009 VA rating decision which denied service connection for hypertension is final.  38 U.S.C. § 7105; 38 C.F.R. § 20.1103.  
11. New and material evidence to reopen the claim for service connection for hypertension has been presented.  38 U.S.C. § 5108; 38 C.F.R. § 3.156.  
12. The June 2009 VA rating decision which denied service connection for a lung disorder is final.  38 U.S.C. § 7105; 38 C.F.R. § 20.1103.  
13. New and material evidence to reopen the claim for service connection for a lung disorder has been presented.  38 U.S.C. § 5108; 38 C.F.R. § 3.156.  
14. The criteria for service connection for a right ankle disorder have not been met.  38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303.  
15. The criteria for service connection for a left ankle disorder have not been met.  38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303.  
16. The criteria for service connection for an ulcer disorder have not been met.  38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303.  
17. The criteria for an effective date prior to March 27, 2013 for the award of service connection for PTSD have not been met.  38 U.S.C. §§ 5103, 5103A, 5107, 5110; 38 C.F.R. §§ 3.102, 3.159, 3.326(a), 3.400.
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran had active service from June 1964 to September 1967.  
Applications to Reopen Claims for Service Connection
A rating decision is final and is not subject to revision upon the same factual basis except upon a finding of clear and unmistakable error where a notice of disagreement or material evidence was not received within one year of notification of the decision.  38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156(b), 20.200, 20.300, 20.1103.  
A claimant may reopen a finally adjudicated claim by submitting new and material evidence.  New evidence means existing evidence not previously submitted to agency decision makers.  Material evidence means 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 final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim.  There is a low threshold to raise a reasonable possibility of substantiating the claim.  38 C.F.R. § 3.156(a); Shade v. Shinseki, 24 Vet. App. 110 (2010); Evans v. Brown, 9 Vet. App 273 (1996); Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998).  
New and material evidence received prior to the expiration of the appeal period will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period.  38 C.F.R. § 3.156(b).  
Type II Diabetes Mellitus and Diabetic Neuropathy
In February 2003, VA denied service connection for Type II diabetes mellitus “because the service medical records did not show any, complaint, treatment, or diagnosis of diabetes mellitus;” “the required service in Vietnam is not shown,” and “nor is there evidence of exposure to herbicides in any other period of service.”  The Veteran did not submit a timely notice of disagreement and the April 2006 rating decision is final.  
The evidence considered in reaching the February 2003 rating decision includes service treatment and personnel records, VA examination and clinical documentation, private clinical documentation, and written statements from the Veteran.  The service treatment records do not refer to diabetes mellitus.  The service personnel records show that the Veteran served at Udorn RTAFB between September 1966 and September 1967.  A February 2001 VA treatment record states that the Veteran was diagnosed with diabetes mellitus.  
New and material evidence pertaining to the issue of entitlement to service connection for Type II diabetes mellitus was not received by VA or constructively in its possession within one year of written notice to the Veteran of the February 2003 rating decision.  Therefore, that decision became final.  38 C.F.R. § 3.156(b).  
The Veteran subsequent sought both to reopen the claim of service connection for Type II diabetes mellitus and to establish service connection for diabetic peripheral neuropathy of the upper and lower extremities.  A June 2009 VA rating decision denied service connection for Type II diabetes mellitus claimed as the result of herbicide agent exposure as “none of the evidence of record establishes that your diabetes mellitus was incurred in or was caused by service, nor that you were exposed to herbicides.”  VA denied service connection for peripheral neuropathy as the “claimed condition and your military service, nor establishes that peripheral neuropathy manifested to a compensable degree within the first year following discharge from service” and “given the fact service connection has not been established for diabetes mellitus, service connection for peripheral neuropathy on a secondary basis cannot be established.”  The Veteran did not submit a timely notice of disagreement and the June 2009 rating decision is final.  
The evidence considered in reaching the June 2009 rating decision includes VA clinical documentation, private clinical documentation, and written statements from the Veteran.  The additional documentation showed ongoing treatment of Type II diabetes mellitus and peripheral neuropathy.  
New and material evidence pertaining to the issues of entitlement to service connection for Type II diabetes mellitus and diabetic peripheral neuropathy was not received by VA or constructively in its possession within one year of written notice to the Veteran of the June 2009 rating decision.  Therefore, that decision became final.  38 C.F.R. § 3.156(b).  
The additional evidence received since the June 2009 rating decision includes VA examination and treatment records, private clinical documentation, and written statements from the Veteran.  An August 2011 written statement from the Veteran indicates that “my barracks was located in the perimeter” of Udorn RTAFB.   
The Board of Veterans’ Appeals (Board) finds that the Veteran’s April 2011 written statement is of such significance that it raises a reasonable possibility of substantiating the claims for service connection.  The documentation addresses the reason of the previous denial as it pertains to the Veteran’s herbicide agent exposure at Udorn RTAFB.  That statement is presumed credible for the purpose of determining whether it is material.  As new and material evidence has been received, the claims of entitlement to service connection for both Type II diabetes mellitus are reopened.  The Board will now address the merits of the claims for service connection 
Service connection may be granted for a recurrent disability arising from disease or injury incurred in or aggravated by active service.  38 U.S.C. § 1110; 38 C.F.R § 3.303 (a).  
Where a Veteran was exposed to an herbicide agent during active service and Type II diabetes mellitus and/or ischemic heart disease becomes manifest to a degree of 10 percent or more at any time after service, service connection shall be established for that disability if the requirements of 38 C.F.R. § 3.307 (a)(6) are met even though there is no record of that disease during service, provided that the rebuttable presumption provisions of 38 C.F.R. § 3.307 (d) are also satisfied.  38 U.S.C. § 1116 (2012); 38 C.F.R. § 3.309 (e).  
Where a veteran was exposed to an herbicide agent during active service and Type II diabetes mellitus becomes manifest to a degree of 10 percent or more at any time after service, service connection shall be established for that disability if the requirements of 38 C.F.R. § 3.307 (a)(6) are met even though there is no record of that disease during service, provided that the rebuttable presumption provisions of 38 C.F.R. § 3.307 (d) are also satisfied.  38 U.S.C. § 1116; 38 C.F.R. § 3.309 (e). 
VA’s Compensation and Pension Service has determined that a special consideration of herbicide exposure on a factual basis should be extended to Air Force veterans whose duties placed them on or near the perimeters of certain Royal Thai Air Force bases anytime between February 28, 1961, and May 7, 1975.  The listed Thai military facilities include Udorn.  If a Veteran’s service duties, as shown by evidence of daily work duties, performance evaluation reports, or other credible evidence, placed him near the air base perimeter, then VA is to concede herbicide exposure on a direct or facts found basis.  VA Adjudication Procedures Manual, M21-1MR, Part IV.ii.2.C.10.q.  
The August 2011 written statement from the Veteran indicates that “my barracks was located in the perimeter” of Udorn RTAFB.  The Board notes that aerial photographs of Udorn RTAFB show barracks near the base’s perimeter.  
The Board finds that the Veteran’s written statement as to both his proximity to the perimeter of Udorn RTAFB to be consistent with his military duties and documented associated activities.  Therefore, the Veteran’s presumed exposure to herbicide agents while stationed at Udorn RTAFB is conceded.  
VA clinical documentation dated in December 2011 shows that the Veteran was diagnosed with Type II diabetes mellitus.  VA clinical documentation dated in September 2013 reflects that the Veteran was diagnosed with peripheral neuropathy of the upper and lower extremities.  
Resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran was exposed to herbicides while stationed at Udorn RTAFB and subsequently manifested Type II diabetes mellitus following service separation.  Therefore, the Board concludes that service connection for Type II diabetes mellitus is warranted.  38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102.  
Service connection may also be granted for disability which is proximately due to or the result of a service connected disease or injury.  38 C.F.R. § 3.310(a). Service connection shall be granted on a secondary basis under the provisions of 38 C.F.R. § 3.310(a) where it is demonstrated that a service connected disorder has aggravated a nonservice connected disability.  Allen v. Brown, 7 Vet. App. 439 (1995).  
Given the establishment of service connection for Type II diabetes mellitus, the Board concludes that service connection for diabetic peripheral neuropathy of the upper and lower extremities is now warranted.   
Heart Disorder
A June 2009 VA rating decision denied service connection for a heart disorder as service connection had not been established for Type II diabetes mellitus; “a heart condition on a secondary basis to this condition cannot be established;” and there is also no evidence showing a heart condition was incurred in or aggravated by military service.”  The Veteran did not submit a timely notice of disagreement and the June 2009 rating decision is final.  
The evidence considered in reaching the June 2009 rating decision includes the service treatment and personnel records VA examination and clinical documentation, private clinical documentation, and written statements from the Veteran.  The service treatment records do not refer to a heart disorder.  Private clinical documentation dated in May 2009 conveys that the Veteran was diagnosed with coronary artery disease in March 2004.  
New and material evidence pertaining to the issue of entitlement to service connection for a heart disorder was not received by VA or constructively in its possession within one year of written notice to the Veteran of the June 2009 rating decision.  Therefore, that decision became final.  38 C.F.R. § 3.156(b).  
The additional evidence received since the June 2009 rating decision includes VA examination and treatment records, private clinical documentation, and written statements from the Veteran.  The August 2011 written statement from the Veteran indicates that “my barracks was located in the perimeter” of Udorn RTAFB.   
The Board of Veterans’ Appeals (Board) finds that the Veteran’s April 2011 written statement is of such significance that it raises a reasonable possibility of substantiating the claims for service connection.  The documentation addresses the reason of the previous denial as it pertains to the relationship between the Veteran’s heart disability and active service.  As new and material evidence has been received, the claims of entitlement to service connection for a heart disorder is reopened.  The Board will now address the merits of the claim for service connection 
The Veteran’s presumed exposure to herbicide agents while stationed at Udorn RTAFB has been conceded.  VA clinical documentation dated in June 2011 shows that the Veteran was diagnosed with coronary artery disease and underwent subsequent CABG procedures.  
Resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran was exposed to herbicides while stationed at Udorn RTAFB and subsequently manifested ischemic heart disease following service separation.  Therefore, the Board concludes that service connection for ischemic heart disease to include coronary artery disease and CABG residuals is warranted.  38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102.  
Hypertension and Lung Disorder
A June 2009 VA rating decision denied service connection for both hypertension and a lung disorder as the claimed disorders were not shown during active service; hypertension was not manifested to a compensable degree within one year of service separation; service connection had not been established for Type II diabetes mellitus; and “hypertension and a lung disorder on a secondary basis to this condition cannot be established.” The Veteran did not submit a timely notice of disagreement and the June 2009 rating decision is final.  
The evidence considered in reaching the June 2009 rating decision includes the service treatment and personnel records VA examination and clinical documentation, private clinical documentation, and written statements from the Veteran.  The service treatment records do not refer to either hypertension or a lung disorder.  VA clinical documentation dated in 2009 conveys that the Veteran was diagnosed with hypertension and had pulmonary complaints.  
New and material evidence pertaining to the issue of entitlement to service connection for both hypertension and a lung disorder was not received by VA or constructively in its possession within one year of written notice to the Veteran of the June 2009 rating decision.  Therefore, that decision became final.  38 C.F.R. § 3.156(b).  
The additional evidence received since the June 2009 rating decision includes VA examination and treatment records, private clinical documentation, and written statements from the Veteran.  In September 2006 written statement, the Veteran related that his hypertension was secondary to his diagnosed Type II diabetes mellitus.  The August 2011 written statement from the Veteran indicates that “they sent me to Clark A.F.B., The Philippines, the doctors there said that I had a severe lung infection related to herbicide and insecticide exposure.”  
The finds that the Veteran’s September 2009 and August 2011 written statements are of such significance that they raise a reasonable possibility of substantiating the claims for service connection.  The documentation addresses the reason of the previous denial as it pertains to the relationship between the diagnosed hypertension, the claimed recurrent lung disorder, and active service.  The statements are presumed credible for the purpose of determining whether they are material.  As new and material evidence has been received, the claims of entitlement to service connection for both hypertension and a lung disorder are reopened and will be addressed in the remand below.  

Service Connection for Right Ankle, Left Ankle Disorder, and Ulcer Disorders
The Veteran asserts that service connection for a bilateral ankle disorder and an ulcer disorder is warranted.  He advances no specific contentions as to the claimed ankle and ulcer disabilities.  
Recurrent right ankle, left ankle, and ulcer disorder were not shown during active service or at any time thereafter.  In the absence of any current disability, the Board concludes that service connection for a recurrent right ankle disorder, a recurrent left ankle disorder, and a recurrent ulcer disorder is not warranted.  
Earlier Effective Date
The Veteran asserts that an effective date prior to March 27, 2013, for the award of service connection for PTSD.  He does not make any specific contentions as to when he believes the award of service connection should have been effectuated.  
Generally, the effective date for an award of service connection is the day after service separation or the date entitlement arose, whichever is later, if the claim is received within one year of the date of separation from service.  Otherwise, the effective date will be the date of receipt of the claim or the date entitlement arose, whichever is later.  38 U.S.C. § 5110 (b)(1); 38 C.F.R. § 3.400 (b)(2)(i). 
PTSD originated during active service secondary to the Veteran’s Vietnam War related experiences.  
In a March 2013 informal claim, the Veteran advanced that service connection was warranted for PTSD.  The informal claim was received by VA on March 27, 2013.  
In March 2017, the Agency of Original Jurisdiction granted service connection for PTSD and effectuated the award as of March 27, 2013, the date of receipt of the claim for service connection. 
The Veteran has made no specific argument as to why an earlier effective date for the award of service connection for PTSD is warranted.  The evidence does not show any claim, formal or informal, was received for service connection for the claimed disability prior to the effective date assigned.  
As PTSD originated during active service and as the Veteran’s initial claim for service connection was subsequently received in March 2013, the Board concludes that the appropriate effective date for the award of service connection for PTSD is March 27, 2013, the date of receipt of the initial claim for service connection.  38 U.S.C. § 5110 (b)(1); 38 C.F.R. § 3.400 (b)(2)(i).  The Board finds that the preponderance of the evidence is against the assignment of any earlier effective date. 
REASONS FOR REMAND
1. The issue of service connection for hypertension is remanded.  
The claim for service connection for hypertension has been reopened.  However, the Board finds that further development is needed before the claim can be adjudicated.  
The Veteran contends that service connection for hypertension is warranted secondary to the service connected Type II diabetes mellitus.  
The Board observes that service connection has been established above for both Type II diabetes mellitus and ischemic heart disease including coronary artery disease and CABG residuals.  The Veteran has not been afforded a VA examination which addresses the relationship, if any, between the diagnosed hypertension and the service connected disabilities.  
Clinical documentation dated after January 2014 is not of record.  VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran’s claims.  Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992).  
2. The issue of service connection for cerebrovascular accident residuals is remanded.  
The Board has granted service connection has been granted for ischemic heart disease to include coronary artery disease and CABG residuals in the decision above.  Given the nature of the claimed disorder, the Board finds that the issue of service connection for cerebrovascular accident residuals should be readjudicated.  
3. The issue of a recurrent sleep disorder to include insomnia is remanded.  
The record reflects that the Veteran has been found to have impaired sleep associated with the service connected PTSD.  The record is in conflict as to whether the Veteran has a recurrent sleep disorder separate and distinct from his service connected psychiatric disability.  Therefore, the Board finds that further VA psychiatric evaluation is needed to adequately address the issues raised by the instant appeal.   
4. The issues of an initial rating in excess of 70 percent for the service connected PTSD; a rating in excess of 10 percent for the service connected left ear suppurative otitis media with cholesteatoma; a rating in excess of 10 percent for the service connected bilateral high frequency hearing loss; and a rating in excess of 10 percent for tinnitus is remanded.  
The Veteran was last afforded a VA psychiatric examination in June 2013 and VA ear and audiological examinations in September 2013.  Given the passage of over five years, the Board finds that further VA psychiatric, ear, and audiological evaluation is necessary.  


5. The issue of entitlement to a TDIU is remanded.  
Entitlement to TDIU requires an accurate assessment of the impairment associated with all of the service-connected disabilities.  That claim is also inextricably intertwined with other issues being remanded.
The matters are REMANDED for the following action: 
1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider, who has treated him for any hypertensive, cerebrovascular accident, pulmonary, and sleep disabilities and the service connected PTSD, otitis media, bilateral hearing loss, and tinnitus disabilities.  Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile.  
2. Obtain the Veteran’s VA treatment records dated after January 2014.  
3. Schedule the Veteran for a VA hypertension examination to assist in determining the current nature of any identified hypertensive disability and its relationship, if any, to active service and/or service connected disability.  The examiner must review the record and should note that review in the report.  A rationale for all opinions should be provided.  The examiner should:

(a)  Diagnose all hypertensive disabilities found.  

(b)  Opine whether it is at least as likely as not (50 percent probability or greater) that any identified hypertensive disability had its onset during active service or is related to any incident of service, including presumed exposure to herbicide agents while at Udorn, RTAFB.  

(c)  Opine whether it is at least as likely as not (50 percent probability or greater) that any identified hypertensive disability is due to the ischemic heart disease, diabetes mellitus, and the other service connected disabilities.  

(d)  Opine whether it at least as likely as not (50 percent probability or greater) that any hypertensive disability has been aggravated (permanently increased in severity beyond the natural progress of the disorder) by the ischemic heart disease, diabetes mellitus, and the other service connected disabilities.  

4. Schedule the Veteran for a VA pulmonary examination to assist in determining the current nature of any identified recurrent pulmonary disability and its relationship, if any, to active service and/or service connected disability.  The examiner must review the record and should note that review in the report.  A rationale for all opinions should be provided.  The examiner should:
(a)  Diagnose all recurrent pulmonary disabilities found.  If no recurrent pulmonary disorder is identified, the examiner should specifically state that fact.  
(b)  Opine whether it is at least as likely as not (50 percent probability or greater) that any identified recurrent pulmonary disability had its onset during active service or is related to any incident of service, including presumed exposure to herbicide agents while at Udorn, RTAFB.  
(c)  Opine whether it is at least as likely as not (50 percent probability or greater) that any identified recurrent pulmonary disability is due to the ischemic heart disease, diabetes mellitus, and the other service connected disabilities.  
(d)  Opine whether it at least as likely as not (50 percent probability or greater) that any recurrent pulmonary disability has been aggravated (permanently increased in severity beyond the natural progress of the disorder) by the ischemic heart disease, diabetes mellitus, and the other service connected disabilities.  
5. Schedule the Veteran for a VA psychiatric examination to assist in determining the current severity of the service connected PTSD.  The examiner must review the record and should note that review in the report.  A rationale for all opinions should be provided.  The examiner should:
(a)  State whether any identified sleep symptomatology is a component of the service connected PTSD.  
(b).  Opine as to the impact of the PTSD on the Veteran’s vocational pursuits and whether it is at least as likely as not (50 percent or greater probability) that the Veteran is unable to secure or follow a substantially gainful occupation due to the effects of the PTSD.  If the Veteran is felt capable of work despite the service-connected disabilities, the examiner should describe what type of work and what accommodations would be necessary due to the service-connected disabilities.  
6. Schedule the Veteran for a VA examination to assist in determining the current severity of the service connected left ear suppurative otitis media with cholesteatoma.  The examiner must review the record and should note that review in the report.  A rationale for all opinions should be provided.  The examiner should opine as to the impact of the left ear disability on the Veteran’s vocational pursuits and whether it is at least as likely as not (50 percent or greater probability) that the Veteran is unable to secure or follow a substantially gainful occupation due to the effects of the left ear disability.  If the Veteran is felt capable of work despite the service-connected disabilities, the examiner should describe what type of work and what accommodations would be necessary due to the service-connected disabilities.  

7. Schedule the Veteran for a VA audiological examination to assist in determining the current severity of the service connected bilateral hearing loss disability and tinnitus.  The examiner must review the record and should note that review in the report.  A rationale for all opinions should be provided.  The examiner should opine as to the impact of the bilateral hearing loss disability and tinnitus on the Veteran’s vocational pursuits and whether it is at least as likely as not (50 percent or greater probability) that the Veteran is unable to secure or follow a substantially gainful occupation due to the effects of the bilateral hearing loss disability and tinnitus.  If the Veteran is felt capable of work despite the service-connected disabilities, the examiner should describe what type of work and what accommodations would be necessary due to the service-connected disabilities.
 
J. T. HUTCHESON
Acting Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	Harold A. Beach, Counsel 

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