Citation Nr: 1104578 Decision Date: 02/04/11 Archive Date: 02/14/11 DOCKET NO. 09-18 611 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to an initial compensable evaluation for epididymal cyst with chronic epididymitis. 2. Entitlement to an initial compensable evaluation for right arm impingement syndrome. 3. Entitlement to an initial evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Heather E. Vanhoose, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD N. J. Nardone, Associate Counsel INTRODUCTION The Veteran served on active duty from July 2002 to November 2002, from February 2003 to May 2004, and from July 2007 to August 2007. This matter comes to the Board of Veterans' Appeals (Board) on appeal from February 2008 and February 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The February 2008 rating decision, in pertinent part, granted service connection for epididymal cyst with chronic epididymitis and impingement syndrome of the right arm, each assigned a noncompensable evaluation effective August 12, 2007. By rating action dated in August 2008, the RO assigned a temporary evaluation of 100 percent effective August 4, 2008 for epididymal cyst with chronic epididymitis based on surgical treatment necessitating convalescence, and restored the noncompensable evaluation from October 1, 2008. The February 2009 rating decision granted service connection for PTSD with an evaluation of 30 percent effective August 12, 2007. In July 2010, a video conference hearing before the undersigned Veterans Law Judge was held at the RO. A transcript of that hearing is of record. The issues of entitlement to increased initial evaluations for PTSD, right shoulder impingement, and for epididymal cyst with chronic epididymitis from October 1, 2008 are addressed in the REMAND portion of the decision below and are REMANDED to the RO. VA will notify the Veteran if further action is required on his part. FINDING OF FACT Prior to August 4, 2008, the Veteran's epididymal cyst with chronic epididymitis was manifested by pain and tenderness, and required surgery on August 4, 2008. CONCLUSION OF LAW Prior to August 4, 2008, the criteria for an initial evaluation of 10 percent, but not higher, for epididymal cyst with chronic epididymitis have been more nearly approximated. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2008); 38 C.F.R. §§ 4.7, 4.115a, 4.115b, Diagnostic Code 7525 (2010). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act The Veterans Claims Assistance Act (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2008)) redefined VA's duty to assist the appellant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2010). The notice requirements of the VCAA require VA to notify the Veteran of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2010). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). In an August 2007 letter, issued prior to the rating decision on appeal, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate a claim for service connection, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. This letter also advised the Veteran of how the VA determines a disability rating and assigns an effective date, and the type of evidence which impacts such. A June 2008 letter advised the Veteran regarding his claims for higher ratings. In any event, the appeal stems from the original award of service connection for epididymal cyst with chronic epididymitis. In Dingess, the United States Court of Appeals for Veterans Claims (Court) held that in cases in which service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 490-91; see also 38 C.F.R. § 3.159(b) (2010). Thus, because the notice that was provided before service connection was granted was sufficient, VA's duty to notify in this case has been satisfied. See generally Turk v. Peake, 21 Vet. App. 565 (2008) (where a party appeals from an original assignment of a disability rating, the claim is classified as an original claim, rather than as one for an increased rating); see also Shipwash v. Brown, 8 Vet. App. 218, 225 (1995); see also Fenderson v. West, 12 Vet. App. 119 (1999) (establishing that initial appeals of a disability rating for a service-connected disability fall under the category of "original claims"). The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the appellant. Specifically, the information and evidence that have been associated with the claims file include the service treatment records, the reports of VA examinations, VA treatment reports, private treatment records, written statements from the Veteran, and hearing testimony. As discussed above, the VCAA provisions have been considered and complied with. The appellant was notified and aware of the evidence needed to substantiate this claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran has been an active participant in the claims process by reporting for VA examinations, providing testimony during a hearing before the undersigned Veterans Law Judge, and submitting evidence and argument. Thus, the Veteran has been provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication or to cause injury to the claimant. Therefore, any such error is harmless and does not prohibit consideration of this matter on the merits. See Conway, supra; Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Analysis The Board has reviewed all the evidence in the appellant's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. The provisions of 38 C.F.R. § 4.31 provide that in every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2010). VA's Schedule for Rating Disabilities (38 C.F.R. Part 4) does not provide rating criteria specifically for epididymal cyst with chronic epididymitis. The RO granted service connection in the February 2008 rating decision, rating the disability as analogous to benign neoplasms of the genitourinary system under 38 C.F.R. § 4.115b, Diagnostic Code 7529, and assigning a noncompensable evaluation. Under this code, the disability is to be rated as voiding dysfunction or renal dysfunction, whichever is predominant. In an August 2008 rating decision, the RO awarded a temporary total rating based on convalescence following surgery for the disorder from August 4, 2008 to October 1, 2008, with the noncompensable rating continued thereafter. As will be discussed in the REMAND section, the Board is remanding the claim concerning the evaluation from October 1, 2008. Thus, this decision will address the evaluation assigned prior to the August 4, 2008 period of convalescence. Upon review of the record, the Board finds the more appropriate analogous disability would be epididymo-orchitis under 38 C.F.R. § 4.115b, Diagnostic Code 7525. Under this code, the disability is rated as urinary tract infection. Under 38 C.F.R. § 4.115a, urinary tract infection a 30 percent evaluation may be assigned for recurrent symptomatic infection requiring drainage/frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management. A 10 percent evaluation may be assigned when there is long term drug therapy, 1-2 hospitalizations per year and/or requiring intermittent intensive management. 38 C.F.R. § 4.115a. A rating could alternatively be assigned based on renal dysfunction. Id. Voiding dysfunction is rated as urine leakage, frequency, or obstructed voiding. For continual urine leakage, post surgical urinary diversion, urinary incontinence, or stress incontinence: Requiring the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day is rated as 60 percent disabling; requiring the wearing of absorbent materials which must be changed 2 to 4 times per day warrants a 40 percent evaluation; requiring the wearing of absorbent materials which must be changed less than 2 times per day warrants a 20 percent evaluation. 38 C.F.R. § 4.115a. For urinary frequency, a 40 percent evaluation may be assigned for daytime voiding interval less than one hour; or, awakening to void five or more times per night. A 20 percent evaluation may be assigned for daytime voiding interval between one and two hours, or; awakening to void three to four times per night. A 10 percent evaluation may be assigned for daytime voiding interval between two and three hours, or; awakening to void two times per night. 38 C.F.R. § 4.115a. For obstructed voiding, a 30 percent evaluation may be assigned for urinary retention requiring intermittent or continuous catheterization with marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: 1. post void residuals greater than 150cc; 2. uroflowmetry; markedly diminished peak flow rate (less than 10cc/sec); 3. recurrent urinary tract infections secondary to obstruction; 4. stricture disease requiring periodic dilatation every 2 to 3 months. Obstructive symptomatology with or without stricture disease requiring dilatation 1 to 2 times per year is noncompensable. 38 C.F.R. § 4.115a. The criteria enumerated under renal dysfunction are as follows: Requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular, warrants a 100 percent evaluation. Persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion warrants an 80 percent evaluation. Constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under diagnostic code 7101 warrants a 60 percent evaluation. Albumin constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under diagnostic code 7101 warrants a 30 percent evaluation. Albumin and casts with history of acute nephritis; or, hypertension non-compensable under diagnostic code 7101 warrants a noncompensable evaluation. 38 C.F.R. § 4.115a. Turning to the evidence, the service treatment records show that in August 2007, the Veteran presented several times for treatment of testicular pain and swelling and a small knot in the testes. He rated the pain as severe. Scrotal ultrasound revealed a small 0.7 right sided epididymal cyst. On examination, the nodule on the right epididymus was mildly tender to palpation. He was diagnosed with testicular hydrocele. The Veteran was provided with a VA general medical examination in September 2007. The Veteran reported that he was not working and had last worked in July 2007. He was not using any prescription medications but he would take occasional Aleve for his hydrocele complaints. The Veteran reported that he gets a sharp pain that originates in his scrotum and goes up through his abdomen, especially if he lifts. He said that is why he was not able to work at that time. He could not do any work that required lifting. He said that he had a 7 month old baby that it was difficult for him to take care of. He stated that when he was in Wisconsin earlier that year they were doing a rollover drill and he got hit in the testicle and he had experienced problems since that time. He continued to have pain primarily in the right side of his scrotum and the right testicle. There was tenderness to palpation and it was aggravated by lifting. Aleve did help some with pain relief. The impression of an ultrasound of the scrotum at that time was of a simple epididymal cyst on the right which likely represents the palpated abnormality. No additional abnormality was identified. Urinalysis and complete blood count were unremarkable. The Veteran's levels were Glucose 95, BUN 12, and creatinine 1.0. The examiner's impression included epididymal cyst with chronic epididymitis. VA treatment records dating from February 2008 to August 2008 show that the Veteran sought treatment for his epididymal cyst with chronic epididymitis. In February 2008, he reported that his right testicle hurt so bad that he had to lie down at times. At that time, physical examination revealed that external genitalia were normal to inspection. There were no masses or adenopathy. The Veteran denied dysuria, hematuria, discharge, frequency, urgency, and dyspareunia. The right testicle was slightly tender posteriorly with a small mass/cyst. The assessment included epidermal cyst of the right testicle with increasing pain, and the examining physician noted that a urology referral had been made. In July 2008, the Veteran was seen by urology for a long history of pain in the right testis. The examiner noted that the Veteran had been treated several times with anti-inflammatories and with antibiotics without relief. The Veteran reported that the disability was painful with any activity. He reported that wearing supporters is uncomfortable and had not really helped much with the discomfort. Upon examination, the testes were both normal as was the vasa. The left epididymis was also normal. The entire right epididymis was tender with the globus major being the most tender part. An August 2008 operation report indicates that the Veteran underwent a right epididymodeferentectomy for chronic pain in the right epididymis. The postoperative diagnosis was chronic right epididymitis. The Veteran was seen for a follow-up later that month. He reported that the itching was pretty bad and he had a rash, but overall was doing much better than before the surgery as far as the pain is concerned. Upon examination, the incisions were well healed and there was no evidence of infection and very little swelling. The Veteran testified during a July 2010 video conference hearing before the undersigned Veterans Law Judge. He stated that he has had increased frequency with urination at night and sometimes during the day. He also said that the condition was worsening because there was another cyst forming and he was going to see whether he would need to have it removed. He also endorsed pain at the site that worsens with activities like heavy lifting. He testified that sometimes it just hurts all the time. He said that most of the time when he does anything it causes a lot of sharp pain which shoots down through his leg. He also said that if he eats food that would make him gassy it hurts a lot more. He denied any pain with discharge or urination. He also said that he does have a fairly normal stream of urine. He testified that he takes Aleve, which relieves the pain but not fully. He said that the pain is the worst symptom of his epididymitis and that sometimes he can not do anything because of the hurting. He stated that most of the time he will stay at home in a chair or in bed. After reviewing the evidence of record, the Board finds that prior to August 4, 2008, the symptoms of Veteran's service- connected epididymal cyst with chronic epididymitis more nearly approximate the criteria for a 10 percent rating when rated analogously to epididymo-orchitis under Diagnostic Code 7525. In essence, the Veteran's primary symptom is pain, and a cyst was noted. He required surgery for his complaints, which removed the right epididymis and vas. The Board finds his symptoms more closely approximate the criteria under Diagnostic Code 7525, which assigns a 10 percent rating for symptoms requiring intermittent intensive management. Thus, resolving all doubt in the Veteran's favor, the Board finds that the Veteran is entitled to a 10 percent evaluation for his service-connected epididymal cyst with chronic epididymitis for the period prior to August 4, 2008. However, the Board finds that the Veteran is not entitled to a rating in excess of 10 percent at any time prior to that date. The record does not reflect recurrent symptomatic infection requiring drainage or hospitalization greater than two times per year, nor require continuous intensive management to warrant a higher evaluation under Diagnostic Code 7525. Additionally, there is no evidence suggesting the existence of any renal dysfunction to warrant consideration under the renal dysfunction criteria of 38 C.F.R. § 4.115a. Moreover, prior to August 4, 2008, the Veteran denied urinary symptoms on a February 2008 outpatient evaluation and made no mention of any voiding symptoms to any care provider, including the urological consultation prior to his surgery. On his notice of disagreement, he stated that it was unfair to evaluate his disorder as noncompensable because the condition did not impede urination. The Board acknowledges that the Veteran testified in 2010 that he voids three times at night. However, such was not reported prior to August 4, 2008, and was first mentioned to medical personnel on the March 2009 VA examination. As noted above, the evaluation for epididymal cyst with chronic epididymitis for the period beginning October 1, 2008 is addressed in the REMAND section of this decision. Because no voiding symptoms were reported or objectively shown in the period prior to August 4, 2008, a higher evaluation is not warranted under the voiding dysfunction criteria of 38 C.F.R. § 4.115a. In summary, the Board finds that the Veteran is entitled to an evaluation of 10 percent, but not higher, for his epididymal cyst with chronic epididymitis for the period prior to August 4, 2008. As a final matter, the Board has also considered whether the Veteran's disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extra-schedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2010); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the genitourinary rating criteria reasonably describe the Veteran's disability level and provide for additional or more severe symptoms than currently shown by the evidence. In this regard, the Veteran's symptom was primarily pain with the subsequent need for surgery. His condition was rated analogously to Diagnostic Code 7525, and such symptoms were considered to be consistent with the need for intermittent intensive management under Diagnostic Code 7525. His disability could also be evaluated under the various genitourinary dysfunction criteria, but no such symptoms were identified during the relevant period. Thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluation, which takes into account his symptoms, is therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. ORDER An initial evaluation of 10 percent for epididymal cyst with chronic epididymitis, for the period prior to August 4, 2008, is granted, subject to the governing law and regulations pertaining to the payment of monetary benefits. REMAND After a review of the record, the Board observes that further development is required prior to adjudicating the Veteran's claim for increased initial ratings for PTSD and right arm impingement syndrome, and for an increased initial evaluation for the period from October 1, 2008 for epididymal cyst with chronic epididymitis. With respect to the claim an increased initial evaluation for the period from October 1, 2008 for epididymal cyst with chronic epididymitis, the Board notes the Veteran underwent a VA genitourinary examination in March 2009. During this examination the Veteran endorsed urinary symptoms of urgency and dysuria. He reported a daytime voiding interval of 2 to 3 hours and nocturia of 3 voidings per night. However, it is unclear whether these symptoms are due to the service connected an epididymal cyst with chronic epididymitis, to include the surgery for that condition. In this regard, the examiner provided the diagnosis of right orchialgia status post right epididymodeferentectomy, but did not list the voiding symptoms as a problem associated with the diagnosis. Thus, clarification is needed. In addition, the Veteran testified that he may have another cyst forming. Accordingly, the Board finds that a new genitourinary examination is needed. With respect to the claim for an increased initial rating for PTSD, the Board notes that the Veteran's last VA examination for PTSD occurred in September 2007, approximately 31/2 years ago. After a mental status examination, the examiner assigned the Veteran a Global Assessment of Functioning (GAF) score of 53 and noted moderate symptoms, family dysfunction, and serious problems with vocational functioning. The Veteran has submitted the July 2010 report of a mental status examination by a private psychologist. The diagnoses were PTSD, major depressive disorder and obsessive personality traits. The July 2010 psychologist assigned a GAF score of 45 for major impairment in the current and past year and opined that since the Veteran was awarded his 30 percent PTSD rating, his condition has become much worse and will continue to become much worse without intervention. However, the Board observes that the July 2010 evaluation was apparently the Veteran's initial evaluation with this provider, and while the psychologist indicated that all available medical records had been reviewed, it is unclear what records were reviewed. Moreover, it is unclear whether the other diagnosed disorders are related to PTSD or impact his functioning. In light of the above, the Board finds that a VA examination should be scheduled. Additionally, in an October 2008 evaluation report submitted by the Veteran, a private psychologist noted the existence of a psychiatric evaluation completed by Dr. R. Blackburn in July 2008. The report of such evaluation has not been associated with the claims file. Thus, the Veteran should be asked to properly complete a release form to include the name and address for any private mental health treatment he has received. With respect to the claim for an increased initial rating for impingement syndrome of the right arm, the Board notes that the Veteran's symptoms primarily involve neurological complaints. The last VA examination mentioning a neurological evaluation was the general medical examination conducted September 2007, over 3 years ago. Thus, the Board concludes that a current neurological examination should be conducted. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to provide the names and addresses of all medical care providers who treated him for PTSD, including Dr. R. Blackburn, and for right shoulder impingement since service, as well as who treated him for his epididymitis condition since October 2008. After securing any necessary release, the RO should obtain any records identified by the Veteran which are not duplicates of those already contained in the claims file. 2. After the above has been completed to the extent possible, schedule the Veteran for a VA mental health examination to determine the current nature and severity of the Veteran's PTSD. The claims folder must be made available to and be reviewed by the examiner in conjunction with the examination. All testing deemed necessary should be conducted and the results reported. Following review of the claims file and examination of the Veteran, the examiner should indicate all symptoms related to the Veteran's PTSD. If other psychiatric disorders are diagnosed, the examiner should indicate whether those disorders are related to the Veteran's service connected PTSD. If not, the examiner should indicate which symptoms noted on the examination are related solely to the nonservice connected psychiatric/personality disorder. A Global Assessment of Functioning score for the service-connected PTSD and any related psychiatric disability should be assigned and the examiner should address the impact of the Veteran's PTSD and related psychiatric disability on his occupational functioning. 3. Schedule the Veteran for a VA peripheral nerves examination to determine the nature and extent of the Veteran's right arm impingement syndrome. All tests deemed necessary should be conducted and the results reported. The claims folder must be made available to and be reviewed by the examiner in conjunction with the examination. The examiner should identify all neurological symptoms and any objective indications of neurological disability related to the right arm impingement syndrome. 4. Return the claims file to the physician who signed the March 2009 VA urological examination, if available. Following review of the claims file to include the March 2009 examination report, the physician should provide an opinion as to whether the complaints of urgency, dysuria, daytime voiding every 2 to 3 hours, and voiding 3 times at night are symptoms resulting from the Veteran's post operative epididymal cyst and chronic epididymitis, or whether such symptoms are unrelated to the diagnosed disorder. The examiner should provide the reasoning for the opinions provided. If the original physician is not available, then the claims file should be forwarded to another physician to obtain the requested opinion. If a new examination is deemed necessary to provide the opinion, one should be scheduled. 5. Following the completion of the above, the RO should review the evidence and determine whether the Veteran's claims may be granted. If not, he and his representative should be furnished an appropriate supplemental statement of the case and be provided an opportunity to respond. Thereafter, the case should be returned to the Board for further appellate consideration, if in order. The Board intimates no opinion as to the ultimate outcome of this case. 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 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ______________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs