Citation Nr: 1028513 Decision Date: 07/30/10 Archive Date: 08/10/10 DOCKET NO. 08-07 520 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim for entitlement to service connection for abnormal blood work. 2. Entitlement to service connection for sciatic neuropathy. 3. Entitlement to service connection for back muscle spasm. 4. Entitlement to service connection for constipation secondary to service connected myofascial restrictive syndrome/strain. 5. Entitlement to service connection for hemorrhoids. 6. Entitlement to service connection for anal fissures. 7. Entitlement to service connection for hypertension. 8. Entitlement to service connection for decreased libido. 9. Entitlement to service connection for gastritis. 10. Entitlement to service connection for sleeplessness (sleep apnea). 11. Entitlement to service connection for penile deformity. 12. Entitlement to specially adapted housing. 13. Entitlement to a certificate for a home adaptation grant. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD G. Jackson, Counsel INTRODUCTION The Veteran served on active duty from April 14, 1992 to September 1, 1992. The appeal comes before the Board of Veterans' Appeals (Board) from various rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts. The issues of entitlement to service connection for hypertension, constipation, gastritis, sleeplessness (sleep apnea), and whether new and material evidence has been submitted to reopen the claim for service connection for abnormal blood work are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify you if further action is required on your part. FINDINGS OF FACT 1. The VA has fully informed the Veteran of the evidence necessary to substantiate his claim and the VA has made reasonable efforts to develop such evidence. 2. Sciatic neuropathy was not present in service, nor was an organic disease of the nervous system (sciatic neuropathy) present within one year following service, nor is it causally or etiologically related to the Veteran's service-connected disabilities. 3. Back muscle spasm is a symptom of the Veteran's service connected chronic myofascial restrictive syndrome (multilevel lumbar disc disease), and not a separate disease entity for purposed of VA compensation. 4. Hemorrhoids were not present in service, are not currently present, and are not causally or etiologically related to the Veteran's service-connected disabilities. 5. Anal fissures were not present in service, are not currently present, and are not causally or etiologically related to the Veteran's service-connected disabilities. 6. Penile deformity was not present in service, is not currently present, and is not causally or etiologically related to the Veteran's service-connected disabilities. 7. Decreased libido is a symptom of the Veteran's service connected disabilities, and not a separate disease entity for purposed of VA compensation. 8. The Veteran does not have service-connected disabilities that have resulted in the loss, or loss of use, of both lower extremities, or blindness in both eyes, or the loss of one lower extremity together with residuals of organic disease or injury that affects the functions of balance or propulsion, or loss of one lower extremity together with the loss or loss of use of one upper extremity that affects the functions of balance or propulsion. 9. The Veteran does not have a service connected vision disorder resulting in 5/200 vision or less in both eyes, or the anatomical loss or loss of use of both hands. CONCLUSIONS OF LAW 1. Sciatic neuropathy was not incurred in or aggravated by military service, may not be so presumed, and is not proximately due to or the result of service-connected disabilities. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2008); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2009). 2. Back spasm, a symptom, is not a chronic disorder incurred in or aggravated by military service, and is not proximately due to or the result of service-connected disabilities. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2008); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2009). 3. Hemorrhoids were not incurred in or aggravated by military service, and are not proximately due to or the result of service- connected disabilities. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2008); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2009). 4. Anal fissures were not incurred in or aggravated by military service, and are not proximately due to or the result of service- connected disabilities. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2008); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2009). 5. Penile deformity was not incurred in or aggravated by military service, and is not proximately due to or the result of service-connected disabilities. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2008); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2009). 6. Decreased libido, a symptom, is not a chronic disorder incurred in or aggravated by military service, and is not proximately due to or the result of service-connected disabilities. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2008); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2009). 7. The criteria for assistance in acquiring specially adapted housing have not been met. 38 U.S.C.A. § 2101(a) (West 2002 & Supp. 2007); 38 C.F.R. § 3.809 (2009). 8. The criteria for acquiring a special home adaptation grant have not been met. 38 U.S.C.A. § 2101(b) (West 2002 & Supp. 2007); 38 C.F.R. § 3.809a (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the Courts have been fulfilled by information provided to the Veteran by correspondence dated in April 2006. That letter notified the Veteran of VA's responsibilities in obtaining information to assist in completing his claim and identified the Veteran's duties in obtaining information and evidence to substantiate his claim. (See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a)), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006), Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006). The Board also notes that 38 C.F.R. § 3.159 was recently revised, effective May 30, 2008, removing the sentence in subsection (b)(1) stating that VA will request the claimant provide any evidence in the claimant's possession that pertains to the claim. 73 Fed. Reg. 23,353-23,356 (Apr. 30, 2008). The Veteran has been made aware of the information and evidence necessary to substantiate his claim and has been provided opportunities to submit such evidence. A review of the claims file shows that VA has conducted reasonable efforts to assist him in obtaining evidence necessary to substantiate his claim during the course of this appeal. His service treatment records and VA treatment records have been obtained and associated with his claims file. He has also been provided with VA examinations to assess his claimed disorders. Furthermore, the Veteran has been notified of the evidence and information necessary to substantiate his claim, and he has been notified of VA's efforts to assist him. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). As a result of the development that has been undertaken, there is no reasonable possibility that further assistance will aid in substantiating his claim. Law and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303. As a general matter, service connection for a disability on the basis of the merits of such claim is focused upon (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. See Cuevas v. Principi, 3 Vet. App. 542 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a) (effective before and after October 10, 2006). The Court has held that when aggravation of a nonservice- connected condition is proximately due to or the result of a service-connected condition the Veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clear-cut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." 38 C.F.R. § 3.303 (2006). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102 (2006). Factual Background The Veteran is service connected for major depression, rated 70 percent disabling; and chronic myofascial restrictive syndrome (multilevel lumbar disc disease), rated 60 percent disabling. Effective in December 1996, he was awarded a total rating based on individual unemployability (TDIU). The Veteran is seeking service connection for several disabilities, including sciatic neuropathy of the lower extremities, back muscle spasm, hemorrhoids, anal fissures, decreased libido, and penile deformity. A review of the service treatment records (STRs) reveals that in July 1992, the Veteran was seen complaining of low back pain. He reported that the pain began after he lifted heavy trays. He had pain running down his left leg. A lumbar spine series was negative for a fracture. The assessment was lumbar muscle strain. He was given 48 hours of bed rest. In late July 1992, on a follow-up visit, he related that the pain occasionally radiated down the left lower extremity. He was given a temporary profile to walk, run, bicycle, or swim at his own pace. In early August 1992, he was seen with complaints of having trouble digesting his food, and was unable to eat. He reported that he was under stress, as he was being "chaptered" out of service. Following examination, the diagnosis was stress-related dyspepsia. Maalox was prescribed. During a follow-up visit a few days later, he reported the onset of diarrhea after taking the Maalox. He denied abdominal pain, nausea or vomiting. Following examination, the diagnosis was stress-related dyspepsia, improved with Maalox, and diarrhea, most likely secondary to Maalox. In mid-August 1992, the Veteran did a follow-up visit for his low back pain. It was noted that he had received six treatments of electrical stimulation to the back with temporary results. Objective examination did not note any radiation of pain to the lower extremities. Regarding hemorrhoids, anal fissures, decreased libido, or penile deformity, no complaints or finding were recorded in the STRs. The Veteran was afforded a VA general medical examination in December 1992. He gave a history of the back pain in service. He describe his current back pain problems, noting that the pain was sometimes severe and associated with muscle spasm, and radiated into the left buttock, but denied tingling or numbness in the inferior extremities. An X-ray study of the lumbosacral spine was unremarkable. The assessment was chronic lumbosacral strain injury. Regarding hemorrhoids, anal fissures, decreased libido, or penile deformity, no complaints or finding were recorded on the examination. During a April 1994 VA spine examination, the physician noted no evidence of neurologic dysfunction resulting from the chronic lumbosacral strain. A January 1997 VA spine examination report noted that straight leg raising in both sitting and supine positions was negative for radicular symptoms. Motor and sensory examinations of the lower extremities were normal. Similar findings were noted on an August 1997 VA spine examination report. In a report of contact, dated in August 1998, an unknown caller related that the Veteran bragged about his 100 percent rating (TDIU) from VA. The caller indicated that, despite his back problems, the Veteran drove around in his jeep, played golf and basketball and was a member of an area basketball team with the name "[redacted]". This was confirmed via a paper trail. A September 1998 VA spine examination report found no evidence of sciatic neuropathy. During an October 1998 VA mental disorders examination, the Veteran related that he slept four-to-six hours a night with frequent awakenings. Regarding his sex drive, he reported that it was low, because he was either not in the mood, or his back hurt, but sometimes it was okay. . A February 2001 VA spine examination report found no evidence of radiculopathy. VA outpatient treatment records include an November 2005 note wherein the Veteran reported that he had a 2-year old daughter. In September 2005, the Veteran reported that he had hemorrhoids, and requested suppositories. The Veteran's claim for service connection for sciatic neuropathy, back muscle spasm, hemorrhoids, anal fissures, decreased libido and penile deformity was received in March 2006. During a April 2006 VA fee basis psychiatric examination, the Veteran reported the medication he was taking caused a decrease in his libido. In April 2006, the Veteran underwent a VA fee basis medical examination. Among his complaints was decreased libido. On physical examination, the examiner noted normal genitalia, no hemorrhoids, and a normal rectal examination. In June 2006, the Veteran was seen at a VA pain clinic where he received a lumbar epidural steroid block for right radicular pain extending into the posterior right hip and thigh. In a July 2006 statement, the Veteran indicated that he was awaiting the birth of his second child in February 2007. In March 2009, the Veteran was afforded a VA spine examination. He complained of sharp pain radiating down both lower extremities. Physical examination revealed no muscle spasm (spasticity) and no evidence of neurologic involvement in the lower extremities. The Veteran is seeking service connection for several disabilities, including sciatic neuropathy of the lower extremities, back muscle spasm, hemorrhoids, anal fissures, decreased libido, and penile deformity. Analysis Sciatic Neuropathy of the Lower Extremities Regarding sciatic neuropathy of the lower extremities, service connection is not in order. A review of the numerous VA medical/spine examinations fails to disclose any chronic sciatic neuropathy of the lower extremities. While the Veteran's subjective complaints have been duly recorded, objective findings fail to confirm the presence of the claimed disability. Most recently, in March 2009, physical examination revealed no muscle spasm (spasticity) and no evidence of neurologic involvement in the lower extremities. While the Veteran is competent to provide testimony or statements relating to symptoms or facts of events that he has observed and is within the realm of his personal knowledge, he is not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet.App. 465, 469-70 (1994). Where a determinative issue involves medical causation or a medical diagnosis, competent medical evidence is required. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Although the appellant is competent to provide evidence of visible symptoms, he is not competent to provide evidence that requires medical knowledge. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). In the present case, objective signs of sciatic radiculopathy have not been identified by medical professionals who rely on proven diagnostic tests to make their assessment; however in this case, sciatic neuropathy was not confirmed on testing. In weighing the evidence, the Board is of the opinion that the findings of the examiners must be accepted, and service connection for sciatic neuropathy of the lower extremities is denied. Back Muscle Spasm The Veteran is seeking service connection for back muscle spasm, which is a symptom of a potential condition and not a disability in itself for VA purposes. In this case, the Veteran is service connected for chronic myofascial restrictive syndrome (multilevel lumbar disc disease). Among the symptoms identified in the ratings for back disorders are muscle spasms. While the Veteran may suffer from muscle spasm, this finding, along with other symptoms are considered as part of the underlying disease or disorder, which, in this case, is chronic myofascial restrictive syndrome (multilevel lumbar disc disease) (see 38 C.F.R. § 3.303). As such, service connection is denied. Hemorrhoids, Anal Fissures and Penile Deformity Regarding hemorrhoids, anal fissures, or penile deformity, no complaints or finding were recorded in the STRs. The Veteran has maintained that if not present in service, then these disorders are secondary to his service-connected disabilities. A review of the record reveals no notations indicating that the Veteran has a penile deformity, hemorrhoids or anal fissures. In fact, the report of the April 2006 VA fee basis examination, the examiner noted specifically that the Veteran's genitalia was normal, and that the rectal examination was normal without findings of hemorrhoids. As a general matter, service connection for a disability on the basis of the merits of such claim is focused upon (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. See Cuevas v. Principi, 3 Vet. App. 542 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). In the present case, none of the above-cited criteria are met. While the Veteran contends that he has these disorders, proven diagnostic tests, and objective examination have not confirmed the presence of these disorders. In weighing the evidence, the Board is of the opinion that the findings of the examiners must be accepted, and service connection for hemorrhoids, anal fissures, or penile deformity is denied. Decreased Libido The Veteran maintains that he has decreased libido as a result of medications prescribed for his service-connected disabilities. Decreased libido is a symptom of a disease, and is not a separate disease entity. He is service connected for major depression, and undoubtedly, his medications may affect his psyche and his desire for intimate relations. However, this finding ( decreased libido), along with other symptoms are considered as part of the underlying diseases or disorders for which the Veteran is service connected. As such, service connection is denied. Specially Adapted Housing or a Certificate for a Home Adaptation Grant Law and Regulations A certificate of eligibility for assistance in acquiring specially adapted housing may be provided if, among other things, the Veteran is entitled to service-connected compensation for permanent and total disability due to: (1) the loss, or loss of use, of both lower extremities such as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair, or (2) blindness in both eyes, having only light perception, plus the anatomical loss or loss of use of one lower extremity, or (3) the loss or loss of use of one lower extremity together with residuals of organic disease or injury which so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair, or (4) the loss or loss of use of one lower extremity together with the loss or loss of use of one upper extremity which so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair. 38 U.S.C.A. § 2101(a) (West 2002); 38 C.F.R. § 3.809 (2009). In order for a Veteran to be entitled to a certificate of eligibility for assistance in acquiring special home adaptation, he or she must be entitled to compensation for permanent and total disability that (1) is due to blindness in both eyes with 5/200 visual acuity or less, or (2) includes the anatomical loss or loss of use of both hands. 38 U.S.C.A. § 2101(b) (West 2002); 38 C.F.R. § 3.809a (2009). Factual Background and Analysis In the Veteran's application in acquiring specially adapted housing or special home adaption grant (VA Form 26-4555), received in October 2008, the Veteran noted that he was not confine to a nursing home or medical care facility. He stated that his qualifying condition was that he had been prescribed a back brace and a cane to achieve mobility due to his service connected back condition. In an October 2008 report from the Mercy Hospital, the physician did not make any notations regarding any need for the Veteran to use devices for ambulation. A back strengthening program was recommended. In March 2009, the Veteran underwent a VA spine examination. He described a constant ache in the bilateral lower lumbar region which worsened with certain activities, including prolonged standing and sitting. He had no loss of bowel or bladder function. He reported that he used a cane and a back brace. He had trouble driving. He had mild difficulty with bathing and toileting. He had help with some of his activities of daily living (ADL). On objective examination, he had an antalgic gait favoring the right lower extremity. The examiner remarked that it was feasible that pain and fatigability could significantly limit functional ability during periods of flare ups, or when the joint was used over a period of time. The examiner concluded that the condition had a moderate effect on ADL, occupation and employability. The Veteran is service connected for major depression, rated 70 percent disabling; and chronic myofascial restrictive syndrome (multilevel lumbar disc disease), rated 60 percent disabling. Effective in December 1996, he was awarded a total rating based on individual unemployability (TDIU). In this case, there is no competent medical evidence that the Veteran is blind in both eyes. Additionally, while the record notes the Veteran's disability associated with his chronic myofascial restrictive syndrome (multilevel lumbar disc disease), there is no competent evidence of functional loss in the extremities which would warrant entitlement to benefits based on loss of use an extremity or combination of extremities such as to preclude locomotion without an assistive device. While the Veteran has been prescribed a cane, the examiner did not specifically state that the Veteran was precluded from ambulating without the cane. Where entitlement to specially adapted housing is not established, an applicant may nevertheless qualify for a special home adaptation grant. This benefit requires that the evidence show permanent and total service-connected disability that either results in blindness in both eyes with 5/200 visual acuity or less, or involves the anatomical loss or loss of use of both hands. 38 U.S.C.A. § 2101(b); 38 C.F.R. § 3.809a(b). The evidence of record in this case fails to demonstrate vision of 5/200 or less in both eyes. Moreover, loss of use of both hands has not been demonstrated. Therefore, a special home adaptation grant is likewise not warranted. For the foregoing reasons, the Board concludes that entitlement to specially adapted housing or a special home adaptation grant is not warranted under the applicable criteria, and that the claim must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for sciatic neuropathy is denied. Entitlement to service connection for back muscle spasm is denied. Entitlement to service connection for hemorrhoids is denied. Entitlement to service connection for anal fissures is denied. Entitlement to service connection for penile deformity is denied. Entitlement to service connection for decreased libido is denied. Entitlement to specially adapted housing is denied. Entitlement to special home adaptation grant is denied REMAND The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the Courts are applicable to this appeal. In April 1993, the Veteran was denied service connection for abnormal blood work. He was properly notified of the decision and did not enter a timely appeal. The decision became final. In March 2006, the Veteran requested that this claim be reopened. With regard to the claim to reopen, the Court has held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a), in a claim to reopen a previously finally denied claim, require that VA, by way of a specific notice letter, notify the claimant of the meaning of new and material evidence and of what evidence and information (1) is necessary to reopen the claim; (2) is necessary to substantiate each element of the underlying service connection claim; and (3) is specifically required to substantiate the element or elements needed for service connection that were found insufficient in the prior final denial on the merits. Kent v. Nicholson, 20 Vet. App. 1 (2006). Review of the claims file reveals that notice in this regard to date is incomplete with regard to the claim to reopen the previously denied claim of entitlement to service connection for abnormal blood work. Concerning the remaining issues of entitlement to service connection for hypertension, constipation, gastritis, and sleeplessness (sleep apnea) secondary to the Veteran's service- connected disabilities, a review of the medical evidence in the claims file reflects that he has been prescribed medication for hypertension, gastritis, constipation, and has complained of sleeping disorders on a regular basis. He maintains that these disorders are caused or aggravated by his service-connected disabilities. A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a) The Court has held that when aggravation of a nonservice-connected condition is proximately due to or the result of a service-connected condition the Veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). I t does not appear that the Veteran has been provided a VA medical examination to determine whether hypertension, constipation, gastritis, and sleeplessness (sleep apnea) are caused or aggravated by the service-connected disabilities. In view of the foregoing, these issues are REMANDED for the following actions: 1. The AMC/RO is to provide the Veteran with a notice letter consistent with Kent v. Nicholson, 20 Vet. App. 1 (2006), informing him of the unique character of evidence that must be presented as to his claim concerning whether new and material evidence has been presented to reopen a claim of entitlement to service connection for abnormal blood work. 2. The RO should contact the Veteran and obtain the names, addresses and approximate dates of treatment of all medical care providers who treated the Veteran for hypertension, constipation, gastritis, and sleeplessness (sleep apnea) since March 2005. After the Veteran has signed the appropriate releases, those records should be obtained and associated with the claims folder. All attempts to procure records should be documented in the file. If the AMC/RO cannot obtain records identified by the Veteran, a notation to that effect should be inserted in the file. The Veteran and his representative are to be notified of unsuccessful efforts in this regard, in order to allow the Veteran the opportunity to obtain and submit those records for VA review. 3. The Veteran should be afforded a VA medical examination to determine whether hypertension, constipation, gastritis, and sleeplessness (sleep apnea) are related to (caused or aggravated by) his service- connected myofascial restrictive syndrome (degenerative disc disease ) or major depression, or the medications used to treat those disorders. All indicated tests and studies are to be performed. Prior to the examination, the claims folder and a copy of this remand must be made available to the physician for review of the case. A notation to the effect that this record review took place should be included in the report of the examiner. Based on review of the Veteran's pertinent medical history and with consideration of sound medical principles, the physician should provide the following opinion: Is it at least as likely as not (50 percent or better probability) that the Veteran's hypertension, constipation, gastritis, and sleeplessness (sleep apnea) are caused or aggravated (i.e., chronically worsened) by his service-connected myofascial restrictive syndrome (degenerative disc disease ) or major depression, or the medications used to treat those disorders? The examiner must explain the rationale for all opinions expressed. If the examiner opines that the question cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so (why is the causation unknowable?), must be provided. 4. The Veteran must be given adequate notice of the date and place of any requested examination. A copy of all notifications, including the address where the notice was sent must be associated with the claims folder. The Veteran is to be advised that failure to report for a scheduled VA examination without good cause shown may have adverse effects on his claim. 5. After the development requested above has been completed to the extent possible, the RO should again review the record. If any benefit sought on appeal, for which a notice of disagreement has been filed, remains denied, the appellant and representative, if any, should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action unless otherwise notified. VA will notify the appellant if further action is required on his or her part. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). 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 The Veterans Benefits Act of 2003, Pub. L. No. 108-183, § 707(a), (b), 117 Stat. 2651 (2003) (to be codified at 38 U.S.C. §§ 5109B, 7112). RENÉE M. PELLETIER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs