Citation Nr: 0840808 Decision Date: 11/26/08 Archive Date: 12/03/08 DOCKET NO. 05-34 716 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for neurological changes manifested by dizziness, poor coordination, visual problems, vertigo, nausea, constipation, hallucinations and confusion to include as secondary to a service-connected disorder. 2. Whether new and material evidence has been submitted to reopen a previously denied claim for service connection for a lumbar spine disorder. 3. Entitlement to service connection for a lumbar spine disorder. 4. Entitlement to service connection for peripheral neuropathy affecting the upper extremities to include as secondary to Agent Orange exposure. 5. Entitlement to a rating in excess of 10 percent disabling for peripheral neuropathy of the right leg. 6. Entitlement to a rating in excess of 10 percent disabling for peripheral neuropathy of the left leg. REPRESENTATION Appellant represented by: Puerto Rico Public Advocate for Veterans Affairs ATTORNEY FOR THE BOARD C. Eckart, Counsel INTRODUCTION The veteran served on active duty from March 1967 to January 1970. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. This includes a June 2005 rating decision which denied ratings in excess of 10 percent disabling for peripheral neuropathy of the bilateral lower extremities, denied service-connection for peripheral neuropathy of the bilateral upper extremities and denied reopening a previously denied claim for service connection for a lumbar spine disorder. This matter also comes before the Board from a rating decision of February 2007 which denied entitlement to service connection for a disorder manifested by neurological changes to include as secondary to a service-connected disorder to include medications take for such disorder. The reopened claim for service connection for back disorder, the service connection claim for peripheral neuropathy of the upper extremities and the issues of entitlement to increased ratings for peripheral neuropathy of the bilateral lower extremities are REMANDED to the agency of original jurisdiction (AOJ) via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. FINDINGS OF FACT 1. Service connection is in effect for diabetes mellitus, peripheral neuropathy of both legs, depressive disorder and erectile dysfunction. 2. The medical evidence reflects that the veteran has a neurological disorder that is as likely as not related to medications to treat his service-connected conditions. 3. A January 2003 rating decision denied the veteran's claim for service connection for a back disorder. The veteran was provided notification of the rating decision and of his appellate rights later in January 2003; however, he did not appeal this determination. 4. New evidence received since the January 2003 rating decision does relate to an unestablished fact necessary to substantiate the claim. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in favor of the veteran, a neurological disorder was caused or aggravated by his service-connected disorders. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2008); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2008). 2. The January 2003 rating decision denying service connection for a back disorder is final. 38 U.S.C.A. § 7105 (West 2002 & Supp. 2008); 38 C.F.R. §§ 20.302, 20.1103 (2008). 3. New and material evidence has been received since the January 2003 rating decision, and the claim for service connection for a back disorder is reopened. 38 U.S.C.A. § 5108 (West 2002 & Supp. 2008); 38 C.F.R. § 3.156 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Assist The VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2008); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2008). In this case, the Board is reopening the claim for service connection for a back disorder, and for the issue of service connection for a neurological disorder secondary to medications for a service-connected condition, is granting in full the benefit sought on appeal. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be further discussed. II. Service Connection The veteran claims that service connection is warranted for a neurological disorder manifested by dizziness, poor coordination, visual problems, vertigo, nausea, constipation, hallucinations and confusion, which he alleges is secondary to medication being used to treat his service-connected disorders. Service connection is in effect for diabetes mellitus, peripheral neuropathy of both legs, depressive disorder and erectile dysfunction. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. In addition, service connection may be granted for any disease 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). In order to establish service connection, a claimant must generally submit (1) medical evidence of a current disability, (2) medical evidence, or in certain circumstances lay testimony, of service incurrence or aggravation of an injury or disease, and (3) medical evidence of a nexus or relationship between the current disability and the in-service disease or injury. Pond v. West, 12 Vet. App. 341, 346 (1999). For veterans who had service of ninety (90) days or more during a war period or peacetime service after December 31, 1946, and any chronic disease such as neurological disorders, is manifest to a compensable degree within a year of discharge, there is a rebuttable presumption of service origin, absent affirmative evidence to the contrary, even if there is no evidence thereof during service. 38 U.S.C.A. §§ 1101, 1112, 1113 1137; 38 C.F.R. §§ 3.307, 3.309. In addition, a disability that is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Furthermore, the Court has held that the term "disability" as used in 38 U.S.C.A. §§ 1110, 1131 should refer to "any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service- connected condition." Allen v. Brown, 7 Vet. App. 439, 448 (1995). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A veteran is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See also 38 C.F.R. § 3.102. When a veteran seeks benefits and the evidence is in relative equipoise, the veteran prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Service treatment records are silent for any neurological disorder manifested by the complaints described by the veteran. Both his entrance examination of January 1967 and separation examination of January 1970 and their accompanying reports of medical history are silent for any complaints of a neurological disorder. Likewise, there is no evidence of any neurological disorder with the above described manifestations having developed within one year of his discharge from service. The veteran is noted to have taken medications for multiple medical conditions including his service-connected conditions for a number of years with no evidence of any side effects documented until a May 2004 treatment record revealed that he had received Metformin 1000 for diabetes control, with instructions to take 1/2 a tablet for a 500 milligram dosage which he tolerated well. However, upon receiving a refill of 500 milligram tablets, he developed anxiety and concentration difficulties. He took the refill for 2 weeks and then discontinued it with no further anxiety symptoms. The records document that by October 2005 his active medication list included Acetaminophen for pain, Metformin for diabetes, Rosiglitazone for diabetes, Tramadol for pain, and Buproprion with no purpose given. He was also taking multiple vitamins and selenium and was also prescribed glucose test strips and lancets for his diabetes. By January 2006 he was seen for pain management pharmacy follow-up for pain that included his legs and heels (neuropathy) as well as low back, and his current pain treatment included Gabapentin, 300 milligrams bid, and 400 milligrams at bedtime. He also was on Tramadol 50 milligrams bid, APAP 650 milligrams tid along with the Tramadol, and Lidocane 12 hour patches daily. He referred some improvement with Tramadol and plans included increasing the dosages of Tramadol and Gabapentin. Thereafter Gabapentin and Tramadol were included on the active medication lists. In March 2006, the veteran underwent a VA psychiatric examination which noted the veteran to be taking Gabapentin, buproprion and other medications. He complained of various psychiatric complaints including poor memory and poor concentration, but there was no opinion as to whether this was from a side effect from medications. The veteran was diagnosed with depressive disorder, not otherwise specified (NOS). Also in March 2006 while being treated for complaints that included his low back pain and his neuropathic pain, he was recommended to optimize his Gabapentin usage but with precautions not to drive while optimizing medications, and with other side effects discussed as including daytime somnolence and falls. In August 2006, he was prescribed Wellbutrin for his depressive disorder. In a July 2006 VA neurological examination that addressed the nature and severity of his peripheral neuropathy of the upper and lower extremities, he discussed that Neurontin (gabapentin) helped control his numbness but that it caused daytime somnolence. The rest of the examination discussed his neuropathy symptoms. In January 2007, the veteran was seen in primary care for evaluation of multiple medical conditions including his diabetes. He complained that his neuropathy was driving him crazy with persistent leg numbness. He referred that a combination of Gabapentin and Tramadol caused him somnolence, anxiety, concentration problems and memory problems. The Gabapentin was noted to have been decreased to 100 milligrams. He was using Tramadol 25 milligrams, with no improvement on pain. Plans included discontinuing Tramadol as he was not obtaining any benefit from it and increasing Gabapentin to 200 milligrams. The treating doctor gave an opinion that a combination of Gabapentin, Tramadol and Wellbutrin could be causing some of the veteran's symptoms described as anxiety and concentration problems. Plans included a consultation with psychology. Later in January 2007 the veteran underwent a VA examination to address his specific neurological complaints that he attributed to medications to treat his service-connected disorders. The claims file and CPRS and CAPRI were reviewed. The veteran was noted to have been treated in the pain clinic and given for the first time Gabapentin 400. He then began experiencing distortion of everything including time and space becoming confused and disoriented. The Gabapentin was mixed with Tramadol and Bupropion. The Gabapentin was slowly reduced to the current 100 milligram level but has never been stopped altogether. The neuropathy symptoms continued unabated with no response to the Gabapentin. Physical examination revealed normal strength, muscle tone and bulk. Sensory exam to light touch was normal. There was no history of trauma or neoplasm to the central nervous system. Pinprick, vibratory sense and position were normal. Cranial nerves were intact and fundoscopic, mental status and cerebellar exams were normal. There was no chorea or carotid bruit. His active medications were as follows: Alcohol prep pad, bupropion, gabapention, clotrimazole, lidocane, lisinopril, metformin, omeprazole, rosiglitazone, tramadol and vardenafil. Subjective complaints were identical to those expressed by the veteran in the January 2006 primary care note in regards to his physical complaints and he again reported that that a combination of Gabapentin and Tramadol caused him somnolence, anxiety, concentration problems and memory problems. Again the history of dosage changes as reported in the recent primary care report. The examiner also recited findings from a September 2006 computed tomography (CT) of the head which was normal. The examiner diagnosed neurological changes secondary to medications side effects. The problems associated with this diagnosis included a condition secondary to medication. The affects included memory loss, decreased concentration, decreased manual dexterity and vision problems. The veteran also described hallucinations when taking high doses of Gabapentin. The effects of this condition on activities of daily living were discussed. The examiner provided a medical opinion as to whether the currently claimed neurological condition was secondary to medications taken for service-connected conditions and stated that this condition was as likely as not caused by the veteran's taking Gabapentin for neuropathy. The rationale for this opinion was that the neurological symptoms, all subjective, can be attributed to the intake of Gabapentin together with bupropion and Tramadol. The examiner commented that it was a pity that all these medications were not stopped temporarily to better assess the effect, but that the veteran must receive the benefit of the doubt. VA treatment records from 2007 include treatment for psychiatric complaints, with high levels of anxiety repeatedly addressed, as well as memory loss and concentration problems. A March 2007 psychiatric treatment note suggested that the veteran's memory lapses were probably influenced by his high anxiety levels. However the records from 2007 also discuss continued side effects from the veteran's medication usage to treat his service-connected conditions. A March 2007 pharmacological pain management record noted the adverse effects of pain medication including mild drowsiness and dizziness with Gabapentin, which he continued to take at 100 milligram doses. Specifically he complained of dizziness which was under control. In May 2007, he again complained of dizziness with Tramadol and was still using Gabapentin. Based on a review of the evidence, the Board finds that the evidence supports a grant of service-connection for a neurological disorder, as the medical evidence in the form of the VA examiner's opinion of January 2007 diagnosed neurological changes secondary to medications side effects and determined that this was as likely as not due to his medication used to treat his service-connected neuropathic condition. This opinion is bolstered by other VA medical evidence showing side effects from the medications taken for his service-connected neuropathy, including the most recent records from March 2007 and May 2007 which showed manifestations of dizziness and sleepiness caused by the medications used to treat his service-connected disorders. There is no medical evidence to clearly contradict January 2007 VA examiner's conclusion, although the evidence does suggest that some of the claimed symptoms including memory and concentration problems could also be due to a service- connected depressive disorder. However, other neurological manifestations, including the dizziness and sleepiness are not attributable to any disorder other than medication side effects. Thus, with consideration of reasonable doubt, service-connection is warranted for the veteran's neurological changes secondary to medication used to treat his service-connected disorders. . III. New and Material Evidence Service connection was first denied for a lumbar spine disorder by the RO in a July 1997 rating decision with notice sent the same month. The veteran did not appeal this decision, but filed another claim for service connection in September 1997. The RO denied service connection for a lumbar spine disorder again in December 1997 with notice sent the same month. The veteran did not appeal this decision and it became final. Thereafter service connection for a lumbar spine disorder was most recently denied by the RO in a January 2003 rating decision, with notice sent the same month. The veteran did not appeal this decision and it became final. He filed his claim to reopen in March 2005. Prior unappealed decisions of the Board and the RO are final. 38 U.S.C.A. §§ 7104, 7105(c); 38 C.F.R. §§ 3.160(d), 20.302(a), 20.1104. If, however, new and material evidence is presented or secured with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. Manio v. Derwinski, 1 Vet. App 145 (1991). When determining whether additional evidence is new and material, VA must determine whether such evidence has been presented under 38 C.F.R. § 3.156(a) in order to have a finally denied claim reopened under 38 U.S.C.A. § 5108. New evidence means existing evidence not previously submitted to agency decision makers. 38 C.F.R. § 3.156(a). 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. Id. The Board has a legal duty to address the "new and material evidence" requirement regardless of the actions of the RO. If the Board finds that no new and material evidence has been submitted it is bound by a statutory mandate not to consider the merits of the case. Barnett v. Brown, 8 Vet. App. 1, 4 (1995), aff'd, 83 F.3d 1380 (Fed. Cir. 1996); see also McGinnis v. Brown, 4 Vet. App. 239, 244 (1993). Among the evidence before the RO in January 2003 were service treatment records that were silent for any lumbar spine disorder on the entrance examination of January 1967 or for any history of such complaints in the accompanying report of medical history. The service treatment records are likewise silent for any treatment for low back problems or complaints regarding the back. However the records do reflect that in April 1967 he was hospitalized for an acute gastroenteritis with cardiovascular collapse and underwent various diagnostic tests for this illness, including a spinal puncture taken without anesthesia. The illness itself did not include low back complaints but were significant for left leg tenderness and spasticity in the muscle of the leg as well as some mild neck stiffness. The spinal fluid culture was negative for any organism. His separation examination of January 1970 revealed a normal spine and the accompanying report of medical history revealed him to deny any history of back problems. Also before the RO in January 2003 was the report of a VA examination from an unclear month in 1972 which on musculoskeletal examination primarily focused on problems with his lower extremities and did not refer any low back symptoms. A special neurological examination done in May 1972 in conjunction with this evaluation did include a history of back pain aggravated by cold weather in addition to leg pain present since service. Examination primarily focused on the findings of tenderness in both legs, but with straight leg raising negative and no significant findings regarding the low back. The impression was no neurological deficit. Also before the RO in January 2003 was a March 1987 Agent Orange examination which revealed on examination of the back and he was also neurologically unremarkable. In July 1997, the RO denied service-connection for a back disorder as not well grounded based on there being no record of treatment for the back in service and normal findings for the back in the March 1987 Agent Orange examination. The RO denied this claim again in December 1997 noting that the veteran's statements regarding recent treatment of a back condition failed to establish a well grounded claim. Also before the RO in January 2003 were VA records of treatment from 1997, and 1999 through 2001. Low back pain was shown in a June 1997 referral to physical therapy (PT). In September 1999, he was diagnosed with chronic low back pain secondary to bulging disc and degenerative joint disease (DJD). He was treated for back pain in 2000 and underwent PT from April 2000 to May 2000 for low back pain secondary to degenerative changes with a magnetic resonance imaging (MRI) from 3 years earlier showing L4-5 bulging disc. In August 2000 he was diagnosed with discogenic disease and a December 2000 barium enema was significant for degenerative changes of the lumbar spine. The report of a March 2002 VA examination for diabetes also before the RO in January 2003 noted neurological symptoms of low back pain. Neurological examination noted disc problems at L2, L3 and L4. VA treatment records include a November 2002 note which reviewed a March 1997 lumbar scan showing degenerative disc disease (DDD) at L4-5 and facet joint hypertrophy and ligamentous thickening at this level as well as moderate canal narrowing. Among the evidence submitted after January 2003 were records of treatment from 1971 to 1972 showing evidence of lumbar spine complaints. This includes a January 1971 record giving a history of pain in both lower extremities and his back since serving in the Army. Straight leg raise was positive at 60 degrees bilaterally and there was some tenderness at the L5-S1 level but no spasm. He was diagnosed with fibromyositis lumbosacral and hamstring contracture. Records from November 1971 gave a history of pain and weakness over both lower extremities since June 1967 and X-rays from that month revealed spina bifida occulta of S1. Following examination, the impression was myositis of the lumbosacral parevertebral muscles. Also submitted after January 2003 were diagnostic test records showing lumbar pathology including a private X-ray of the lumbosacral spine from December 1994 showing a narrowed L4-5 disc space with end plate scoliosis on the basis of discogenic disease. A January 2005 X-ray showed degenerative changes at L4-5 and a February 2005 MRI likewise showed degenerative changes and DDD of L4-5 with an intervertebral disc herniation and segmental canal stenosis. VA records from 2005 to 2006 reflect continued treatment for complaints of low back pain due to these degenerative changes. The Board finds that the additional evidence submitted since January 2003 is new and material as it now shows the veteran had treatment records showing back complaints within a year of his discharge from service, as well as current evidence of degenerative changes to the lumbar spine. This raises the possibility of an arthritis condition having manifested within a year of service. The additional records also show the presence of a spina bifida occulta, a preexisting congenital condition. Congenital or developmental defects are not diseases or injuries within the meaning of the applicable legislation. See 38 C.F.R. §§ 3.303(c), 4.9 (2008); see also Winn v. Brown, 8 Vet. App. 510, 516 (1996). A disease which is considered by medical authorities to be of familial (or hereditary) origin must, by its very nature, be found to have pre-existed a claimant's military service, but service connection could be granted if there is superimposed injury or disease in service and the preexisting disorder is aggravated (permanently increased in severity) during service. VAOPGCPREC 82-90. This evidence was not previously before the RO which had denied the service connection claim for based on there being no evidence of a lumbar spine in service. This evidence is significant in that it not only shows a current lumbar spine disorder but also a possible service related cause for this disorder, either as presumptive under 38 C.F.R. § 3.307, 3.309, or on a direct basis, or even based on a superimposed injury to a preexisting spina bifida. Such evidence, when considered in light of the previous evidence, which does include evidence of a lumbar spine puncture in service, now raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2008). ORDER Service connection for a neurological condition as secondary to medication side effects is granted. New and material evidence sufficient to reopen the veteran's claim for service connection for a back disorder has been received and the claim is reopened. To this extent, the appeal is granted. REMAND As noted above, the claim for entitlement to service connection for a back disorder was reopened based on the submission of new and material evidence. The veteran has also appealed denials of service connection for peripheral neuropathy of the upper extremities and an increased rating for peripheral neuropathy of the lower extremities. The Board notes that these issues were most recently adjudicated in a supplemental statement of the case issued in October 2006. Subsequently, the VA obtained additional evidence including VA records from 2007 as well as examinations from 2007. Thus readjudication is necessary for all of these issues to include consideration of this additional VA generated evidence. In regards to the lumbar spine issue, the Board finds that a VA examination is necessary to ascertain the nature and etiology of this condition, to include whether aggravation of a preexisting spina bifida occulta shown in the X-rays from 1971 via an intercurrent injury took place during service. While the service records do not reflect actual back complaints, they do reflect that the veteran underwent a lumbar puncture in March 1967. An examination should address whether this puncture caused or aggravated his current problems. As there is evidence of current degenerative disease, the examiner should also discuss whether such disease was manifest within a year of his discharge from service. In regards to the peripheral neuropathy for the upper extremities, the Board notes that the veteran has specifically alleged that this condition is related to Agent Orange exposure. Although an examination to address the etiology of this condition was done in July 2006 and determined that this was not a diabetic neuropathy, the examiner did not address whether this condition is related directly to Agent Orange exposure, or is a disease presumptive to such exposure. As the veteran is presumed to have exposure to Agent Orange, another examination should discuss the relationship of this exposure and the neuropathic condition of the upper extremities. In regards to the question of entitlement to higher ratings for the peripheral neuropathy affecting both legs, the Board finds that in light of the additional evidence received since the most recent examination of October 2006, some of which suggests a possible worsening of symptoms, a new VA examination should be scheduled to discuss the severity of this condition. VA's duty to assist the veteran includes obtaining relevant medical records and a thorough and contemporaneous medical examination in order to determine the nature and extent of the veteran's disability. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2008). Additionally, during the pendency of this appeal, the United States Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the VA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. In the present appeal, the veteran was provided with a generic notice pursuant to Dingess, supra. In light of the need to remand these matters for further development, additional notice should specifically address the issues on appeal. In addition, there has been a recent decision by the Court addressing increased rating claims, Vasquez-Flores v. Peake, 22 Vet. Ap. 37, 2008, which points out that for an increased- compensation claim, section § 5103(a) requires, at a minimum, that the Secretary notify the claimant that, to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Further, if the Diagnostic Code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant. Additionally, the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life. Vazquez- Flores v. Peake, supra. Accordingly, the case is REMANDED for the following action: 1. The AOJ must send the appellant a corrective notice, that explains (1) the information and evidence not of record needed to establish an effective date, if an increased rating is granted on appeal, as outlined by the Court in Dingess, supra, (2) that he can submit medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life, (3) generally, the criteria necessary for entitlement to a higher disability rating, (4) that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life, and (5) types of medical and lay evidence that the claimant may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation-e.g., competent lay statements describing symptoms, medical and hospitalization. Vazquez- Flores, supra. The AOJ must also send the veteran a corrective notice addressing the service connection claim, that includes: (1) an explanation as to the information or evidence needed to establish a disability rating and an effective date, if service connection is granted. (c) The notice regarding both the service connection and increased rating issues must also (1) inform him of what he needs to provide, and (2) what information VA has or will provide. The claims file must include documentation that there has been compliance with the VA's duties to notify and assist a claimant as specifically affecting the issues on appeal. 2. The AOJ should contact the veteran to determine the names, addresses, and dates of treatments of any and all private medical care providers, who treated him for back problems and peripheral neuropathy of the upper extremities since his discharge from service and for his peripheral neuropathy of his lower extremities since 2007. After securing the necessary release(s), the AOJ should obtain these records. All correspondence, as well as any treatment records obtained, should be made a part of the claims folder. If private treatment is reported and those records are not obtained, the veteran and his attorney should be provided with information concerning the negative results and afforded an opportunity to obtain the records. 38 C.F.R. § 3.159 (2007). 3. Thereafter following completion of the above, the AOJ should schedule the veteran for a VA orthopedic examination, by an appropriate specialist, to determine the nature and etiology of the veteran's claimed back disability. The claims folder must be made available to the examiner prior to the examination, and the examiner should acknowledge such review of the pertinent evidence in the examination report. All indicated studies should be performed and all manifestations of current disability should be described in detail. The examiner should address the following: (a) Does the veteran have any current, chronic back disability? If so, is it at least as likely as not that any current back disability began in service or became manifest to a compensable degree within one year of service? (b) If any diagnosed back disorder is shown to have preexisted service, was there (1) a pathological worsening of the preexisting condition during service? and (2) if yes, was the increase in severity due to the "natural progress" of the disorder or was the increase beyond that which would be considered the "natural progress" of the disorder; (3) if any preexisting condition is shown to be a congenital condition of the back, was it subject to a superimposed injury, as the result of active service? In answering these questions, the examiner must consider all service treatment records showing a lumbar puncture. Each opinion should contain comprehensive rationale based on sound medical principles and facts. 4. After completion of the above, the AOJ should schedule the veteran for a VA neurological disorders examination(s), to (1) determine the nature and etiology of the veteran's claimed bilateral peripheral neuropathy of the upper extremities and (2) determine the nature and extent of the veteran's service- connected bilateral peripheral neuropathy of the lower extremities. The claims file, this remand, and treatment records must be made available to the examiner(s) for review of the pertinent evidence in connection with the examination(s), and their reports should so indicate. All indicated tests or studies deemed necessary for an accurate assessment should be done. (A). In addressing the peripheral neuropathy of the upper extremities, the examiner should address the following: Does the veteran have any current, chronic neurological disability of the upper extremities? If so, is it at least as likely as not that any current neurological disability of the upper extremities began in service, is a disease that is either presumptive to Agent Orange exposure, or if not a presumptive disease, was directly due to Agent Orange exposure in service, or became manifest to a compensable degree within one year of service? In giving such opinion the examiner should also address the findings and opinion from the VA neurological examination of July 2007 regarding the neuropathy of the upper extremities. (B) In addressing the peripheral neuropathy of the lower extremities, the neurological examiner is to assess the current nature and extent of severity of the veteran's neurological impairment related to his service-connected bilateral peripheral neuropathy of the lower extremities in accordance with the latest AMIE worksheet for rating neurological disorders. The Diagnostic Codes applicable to nerve impairment distinguish the types of paralysis-- complete and incomplete. Under incomplete paralysis, the degree of paralysis is further broken down into three or four categories: severe, moderately severe, moderate, and mild. With these categories in mind, the examiner should classify the appellant's upper extremity impairments, distinguishing among the categories and using the results of all pertinent testing of record. The examiner must provide a comprehensive report including complete rationales for all conclusions reached. 5. Following completion of the above development, the AOJ should readjudicate the veteran's claims. If the benefit sought on appeal remains denied, the veteran should be provided a supplemental statement of the case, which reflects consideration of all additional evidence received and all applicable regulations. It must contain notice of all relevant actions taken on the claim for benefits, to include a summary of the evidence and discussion of all pertinent regulations. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. No action by the veteran is required until he receives further notice; however, the veteran is advised that failure to cooperate by reporting for examination without good cause may result in the denial of the claim(s). 38 C.F.R. § 3.655 (2008). The appellant and his representative have the right to submit additional evidence and argument on the matter 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.A. §§ 5109B, 7112 (West Supp. 2008). ____________________________________________ A. BRYANT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs