Citation Nr: 1145495 Decision Date: 12/13/11 Archive Date: 12/21/11 DOCKET NO. 06-32 366 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas THE ISSUES 1. Entitlement to service connection for breast cancer, status post mastectomy. 2. Entitlement to service connection for uterine fibroids, status post hysterectomy. 3. Entitlement to service connection for sleep apnea, to include as secondary to service-connected sinusitis. WITNESSES AT HEARING ON APPEAL Veteran and Witness ATTORNEY FOR THE BOARD L. Durham, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1966 to June 1969, from August 1970 to August 1988, and from January 1991 to September 1991. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 2005 rating decision of the VA RO in Waco, Texas. In April 2009, the Veteran testified at a personal hearing before the undersigned Veterans Law Judge. A transcript of this hearing was prepared and associated with the claims file. These issues were remanded by the Board for further development in September 2009. The record reflects that the Veteran recently submitted additional evidence to the Board without a waiver of initial review by the agency of original jurisdiction. See 38 C.F.R. § 20.1304. However, as this evidence only relates to the issues of entitlement to service connection for breast cancer, status post mastectomy and entitlement to service connection for uterine fibroids, status post hysterectomy, and these issues are being granted, as discussed below, the Board will proceed to adjudicate these claims accordingly with no prejudice to the Veteran. At her April 2009 hearing, the Veteran raised the issue of entitlement to service connection for a bilateral knee disability and a shoulder disability. These issues were referred to the RO for appropriate development in the September 2009 Board determination. It does not appear that they have ever been adjudicated. Additionally, it was indicated at the April 2009 hearing that the Veteran is unemployable. Therefore, the issues of entitlement to service connection for a bilateral knee disability and a shoulder disability and entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The issue of entitlement to service connection for sleep apnea, to include as secondary to service-connected sinusitis is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Resolving doubt in favor of the Veteran, her breast cancer, status post mastectomy is shown to be causally related to her active duty service. 2. Resolving doubt in favor of the Veteran, her uterine fibroids, status post hysterectomy is shown to be causally related to her active duty service. CONCLUSIONS OF LAW 1. Service connection for breast cancer, status post mastectomy is warranted. See 38 U.S.C.A. §§ 1110, 1111, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2011). 2. Service connection for uterine fibroids, status post hysterectomy is warranted. See 38 U.S.C.A. §§ 1110, 1111, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims for service connection for breast cancer, status post mastectomy, and uterine fibroids, status post hysterectomy, the benefits sought on appeal have been granted in full, as discussed in the following decision. As such, the Board finds that any error related to the VCAA on these claims is moot. See 38 U.S.C. §§ 5103, 5103A (West 2002 & Supp. 2011); 38 C.F.R. § 3.159 (2011); Mayfield v. Nicholson, 19 Veteran. App. 103, (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Analysis The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110 (West 2002). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (2011). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2011). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111 (West 2002). In order to rebut the presumption of soundness at service entry, there must be clear and unmistakable evidence showing that the disorder preexisted service and there must be clear and unmistakable evidence that the disorder was not aggravated by service. The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. VAOPGPREC 3-2003 (July 16, 2003); Jordan v. Principi, 17 Vet. App. 261 (2003); Wagner v. Principi, No. 02-7347 (Fed. Cir. June 1, 2004). However, where a preexisting disease or injury is noted on the entrance examination, section 1153 of the statute provides that "[a] preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease." 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306(a) (2011). For Veterans who served during a period of war or after December 31, 1946, clear and unmistakable evidence is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service, and clear and unmistakable evidence includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. 38 C.F.R. § 3.306(b) (2011). Temporary or intermittent flare-ups of symptoms of a preexisting condition, alone, do not constitute sufficient evidence for a non-combat Veteran to show increased disability for the purposes of determinations of service connection based on aggravation under section 1153 unless the underlying condition worsened. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The Veteran asserted at the April 2009 hearing that she had uterine fibroids in 1991. At this time, her physicians determined that she should be given hormone replacement therapy (HRT) to shrink the tumors, as opposed to a hysterectomy or getting rid of the tumors. The Veteran asserted HRT grows tumors. She further indicated that she underwent a hysterectomy in 1995 and, once again, her HRT was increased. One year later, she had a bilateral mastectomy. The Veteran indicated that she had previously had abnormal breast imaging that should have been further investigated. Specifically, it was asserted at the hearing that on April 4, 1991, a physician noted 5 masses in her breasts, and no subsequent biopsies, follow-ups, or studies were done. The Veteran claims that the military failed to investigate this matter appropriately. An April 1991 service treatment record reveals that the Veteran was taking Premarin and Provera. The Veteran was noted on a September 1991 Report of Medical Examination as having breast masses with no malignancy indicated on a March 1991 mammogram. An October 1991 VA medical record reveals that the Veteran was taking Premarin and Provera. An October 1992 VA medical record reflects that the Veteran was on estrogen replacement treatment. An August 1995 VA medical record reflects that the Veteran was taking Premarin. August and October 1996 VA medical records reflect that the Veteran was taking estrogen. VA medical records reflect that the Veteran underwent a bilateral mastectomy in 1996 and a total hysterectomy in 1995. The claims file contains an April 2009 letter from a private physician at Baylor Family Medicine at Frisco. This physician indicated that she is a family physician who has treated the Veteran. The physician noted that the Veteran was previously treated with combination hormone therapy for fibroids followed by a hysterectomy in 1995. A year later, the Veteran was diagnosed with estrogen and progesterone receptor-positive breast cancer. The physician noted that, while she cannot say definitively that the hormone replacement therapy received by the Veteran directly contributed to the development of bilateral breast cancer, she can say that combination hormone replacement therapy in post-menopausal women have been shown to increase the risk of breast cancer by 2.3 percent, according to a reanalysis of date from 51 epidemiological studies on this very topic. Research has also shown that 5 years of hormone replacement therapy in patients with a personal history of breast cancer was associated with the development of a new breast cancer almost twice as often as breast cancer survivors who were not placed on hormone replacement therapy for the same length of time. Based on this and other research conclusions (Women's health initiative), estrogen therapy is not recommended to be given to any woman with a personal history of breast cancer, given that even administration of estrogen alone may place the Veteran at "excessive risk" of developing breast cancer. A VA medical opinion was rendered in April 2010. The examiner reviewed the claims file and discussed relevant medical evidence of record. The examiner then concluded that it is as least as likely as not that the Veteran's uterine fibroids were aggravated by the Premarin that she has prescribed while in the military service, as estrogen stimulates growth or uterine fibroids. It appears from an August 24, 1995, note that she was actually on unopposed estrogen, even thought she had an intact uterus. The examiner also concluded that it as least as likely as not that the Veteran's breast cancer was aggravated by the Premarin and Provera that she was prescribed while in the military service. The examiner then referred to WHI study findings on the risk of breast cancer in women taking combined estrogen plus progestin. This study showed that more women taking E+P developed breast cancer than those taking placebo pills. This study showed that, overall there was a 24 percent increase in the risk for breast cancer due to E+P. In contrast, findings from the E+P trial show that women with a uterus who used combined estrogen and progestin had an increased risk of breast cancer by 5 years. These findings suggest that CEE alone is safer in regard to breast cancer than combined estrogen plus progestin, as least in the short term for women who have a hysterectomy and, therefore, would not be prescribed a progestin. A VA medical opinion was rendered in July 2011. The Veteran was not present for examination. The examiner indicated that she reviewed the claims file. The examiner noted that, based on her review, it is evident that the Veteran was started on Premarin/Provera in April 1991 for menopausal symptoms characterized by drenching night sweats. No fibroid was noted at the time. It appears that she was on this for 1.5 years until October 1992 before discontinuing it after discussion with another gynecologist. The examiner noted that the standard of care in the early 1990's was that women were placed on HRT for prevention of cardiovascular disease when they were starting to exhibit menopausal symptoms. Only after the WHI study in 2002 did they stop this practice.) The examiner noted that no mention of a fibroid uterine is made until 1995, at which point, she was noted to have a 9 centimeter fibroid uterus for which she underwent TAH/BSO at the Dallas VA. It is, therefore, unclear whether her 1.5 years of HRT contributed to the growth of the fibroid. It has been suggested by later data that HRT in postmenopausal females may lead to non-regression of fibroids, and may even contribute to growth. The examiner stated that she is not aware of literature stating that premenopausal hormone treatment does the same. The Veteran then underwent TAH/BSO in August 1995, which rendered her menopausal. Post-operatively, she was placed on Premarin alone. This was also the standard of care for menopausal women for prevention of osteoporosis and heart disease. Unopposed estrogen is indicated in hysterectomized women for treatment of menopausal symptoms both then and now. As far as her breast cancer history, as early as October 1992, a physician noted an abnormal examination and suspected metastatic breast cancer. It appears workup was done including MMG referral to Heme. However, this work-up was negative. An October 22, 1992, clinic note indicated a nodular area over the right breast. The Veteran was noted to have a normal breast examination in August 1996 and September 1996. MMG was then performed later in the year that was suspicious and led to diagnosis of breast cancer. If she had remained on her Premarin since her hysterectomy, it would have been a little over a year of Premarin alone. The WHI study indicated that the risk of breast cancer seems to increase with increasing duration of use. The total use of combined HRT in this patient was 1.5 years with an additional 1 year of estrogen alone. (Estrogen alone has not been shown to increase the risks of breast cancer, according to WHI, 2001.) Therefore, it may be difficult to prove that her total of 2.5 years of hormone use (one year of which was estrogen alone) could have contributed to her development of breast cancer, though it is certainly possible. The question is, was there a delay in the diagnosis of breast cancer? Did she already have it in 1992 and it was missed? The examiner indicated that a radiologist may have to be consulted to look at the old films and/or breast surgeon or oncologist on this topic about misdiagnosis of breast cancer though it seems that between 1992 and 1995 her MMGs were deemed okay. A VA medical opinion was rendered in August 2011. The Veteran was not present for examination. The examiner indicated that she reviewed the service treatment records and VA records. The examiner noted that the Veteran had uterine fibroids that were treated with hormone therapy in 1991, with dysfunctional uterine bleeding, and a hysterectomy in 1995. The Veteran had a bilateral mastectomy in November 1996 for left infiltrating intraductal carcinoma and right lobular carcinoma in situ. The examiner determined that the etiology of breast cancer and uterine fibroids is unknown. The factors that increase risk for breast cancer are family history (genetic predisposition), hormone treatment, obesity, increased alcohol intake, tobacco use, and radiation exposure. Trauma is not identified as an increased risk factor. For uterine fibroids, the cause is also unknown. Many women with fibroids have no significant complaints associated with the uterine fibroids. Size and location play a role. Those factors that influence the occurrence of uterine fibroids are family history, ethnic origin, obesity, and increased red meat in the diet. Hormones have an effect, and are used to decrease bleeding and regulate cycles. The standard of care for menometrorrhagia in 1991 was HRT, as it is now. The patient was 43 at the time and not post-menopausal. Menopause will cause a shrinkage of uterine fibroids. The examiner went on to note that the Veteran's HRT treatment may or may not have had an impact on the course of the breast cancer, but did not have an etiologic role in her opinion. The occurrence risk is increased with post menopausal women getting estrogen treatment. For this event, it is therefore as likely as not to have played a role in the course of the disease but less likely to have caused the disease. Regarding her uterine fibroids, the HRT was indicated and in 1991 there were no contradictions to its use. Furthermore, HRT does not cause uterine fibroids, and there played no initial role. When treatment failed, hysterectomy was indicated. It was not a cause for progression to surgery. As discussed, multiple VA medical opinions pertaining to these issues were obtained following the September 2009 Board remand. In a May 2011 deferred rating decision, the RO referenced the need for further medical opinion in order to provide a baseline and discuss the theory of aggravation. The Board notes that, any disability which is proximately due to, or results from, another disease or injury for which service connection has been granted shall be considered a part of the original condition. 38 C.F.R. § 3.310(a) (2011). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice- connected disease or injury. 38 C.F.R. § 3.310(b) (2010); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board presumes that the RO was basing its requests for medical opinions to discuss aggravation and provide a baseline on the aforementioned regulation. However, the Veteran is not claiming service connection for breast cancer, status post mastectomy and uterine fibroids, status post hysterectomy as secondary to service-connected disabilities. As such, 38 C.F.R. § 3.310 is not pertinent to these claims and an opinion addressing a baseline of severity of a disability is not required. Moreover, the Board notes the concerns set forth by the Veteran in her October 2011 statement that she was not examined at the Dallas VA in 2010 and 2011. However, the Board notes that the examination reports from those years do not reflect that she was physically examined but merely that the claims file was examined or reviewed and opinions were rendered based on the reviews of the claims file. The September 2009 remand did not direct that further physical examination must be conducted, only that medical opinions based on reviews of the claims file should be provided. Regulations provide that service connection may be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. 3.303(d) (2011). The Board notes that it is clear from the medical evidence of record that the Veteran was taking Premarin and Provera during her period of service from January 1991 to September 1991. The April 2010 VA medical opinion reflects that it is as least as likely as not that the Veteran's uterine fibroids were aggravated by the Premarin that she was prescribed while in the military service, as estrogen stimulates growth or uterine fibroids, and that it is as least as likely as not that the Veteran's breast cancer was aggravated by the Premarin and Provera that she was prescribed while in the military service. Additionally, the April 2009 private physician at Baylor Family Medicine at Frisco stated that, while she cannot say definitively that the HRT received by the Veteran directly contributed to the development of bilateral breast cancer, she can say that combination HRT in post-menopausal women have been shown to increase the risk of breast cancer by 2.3 percent, according to a reanalysis of date from 51 epidemiological studies on this very topic. Therefore, as the Veteran was clearly taking Premarin and Provera while on active duty, and the claims file contains a medical opinion indicating that it is as least as likely as not that Premarin and Provera were a significant contributing factor in the Veteran's development of breast cancer and uterine fibroids, the Board finds that the evidence of record is at least in equipoise as to whether the use of HRT during service contributed to the Veteran's development of breast cancer and uterine fibroids, requiring a mastectomy and hysterectomy. Resolving all reasonable doubt in favor of the Veteran, the Board will grant the Veteran's claim of service connection for breast cancer, status post mastectomy, and uterine fibroids, status post hysterectomy. ORDER Entitlement to service connection for breast cancer, status post mastectomy is granted. Entitlement to service connection for uterine fibroids, status post hysterectomy is granted. REMAND The Veteran is seeking entitlement to service connection for sleep apnea, to include as secondary to service-connected sinusitis. Having reviewed the claims file, the Board finds that additional development is necessary prior to the adjudication of this claim. The Veteran essentially asserts that she has sleep apnea as a result of her service-connected sinusitis or sinus operations that she underwent in 1985 while in Germany and in 2003. A review of the Veteran's service treatment records reveals that she reported poor sleep in a January 1987 service treatment record. The Veteran reported having frequent trouble sleeping on a May 1988 Report of Medical History. In a September 1989 VA examination report, the Veteran reported increasing sleeplessness. An October 1990 VA medical record reflects that the Veteran took sleeping pills. The Veteran reported in a March 1991 and a September 1991 Report of Medical History that she had frequent trouble sleeping. In a September 1992 VA medical record, the Veteran reported taking pills to help her sleep in 1987 while in Germany. The Veteran underwent a VA examination in December 1992, at which she reported that she began to experience decreased sleep in 1987. In a March 1993 VA medical record, the Veteran was noted as having sleep dysfunction. In a January 2003 VA medical record, the Veteran was noted as having obstructive sleep apnea. In an April 2004 VA medical record, it was noted that the Veteran has slept less than 4 hours per night for many years. The Veteran underwent a VA examination in December 2004. The examiner reviewed the claims file and noted that the Veteran was diagnosed with sleep apnea by a sleep study. It was noted that she had sinusitis and has some sinus surgery done in 1986. Subsequently, she also had a nasoseptal rhinoplasty and laser assisted uvuloplasty done in January 2003, after which her sinus symptoms improved. This was also done prior to her starting C-PAP. The Veteran was diagnosed with sleep apnea stable on C-PAP. The examiner concluded that it is not likely that her sinusitis caused her sleep apnea. However, this could not be her only cause for sleep apnea as septoplasty and uvuloplasty did not cause improvement in the sleep apnea as she did require C-PAP post surgery. In July 2006, the Veteran underwent a VA examination. At this examination, the Veteran provided a history of obstructive sleep apnea, moderate degree. The Veteran reported having had a nasal septoplasty done while on active duty in 1988 and having had a revision septoplasty and UPPP done at the Dallas VA Medical Center (VAMC) in January 2003. It was noted that she is currently on a C-PAP machine and indicated that the surgical procedure done in January 2003 was necessary so that she could utilize her C-PAP machine. The examiner noted that a review of the Veteran's service treatment records was negative for complaints of sleep apnea and/or treatment of sleep apnea while on active duty. The Veteran was diagnosed with obstructive sleep apnea. The examiner noted that, at the present time, the Veteran does not have evidence of significant nasal obstruction and does not have evidence of acute or chronic sinusitis. However, even if this were the case, current medical literature would not support causation between sinusitis and obstructive sleep apnea. In any case, the examiner opined that the Veteran's current obstructive sleep apnea would not be secondary to her chronic sinusitis and not secondary to previously done nasal surgery. A VA medical opinion was rendered in March 2010. The examiner reviewed the claims file and noted that the Veteran was diagnosed with obstructive sleep apnea on the basis of a polysomnogram on December 18, 2002. The examiner noted that he had previously evaluated the Veteran on October 28, 2002. At the time, she reported a history of apneas for 3 years. She also reported weight gain of 100 pounds over the preceding 10 years. The examiner determined that it is less likely than not that Veteran's sleep apnea was incurred or aggravated by her miliary service. There is no record of sleep apnea while on active duty and the Veteran initially reported onset of apneas several years after discharge. The examiner noted that it is less likely than not that the Veteran's sleep apnea was caused or aggravated by her service-connected sinusitis. There is no anatomic or physiologic correlation between these 2 conditions. The Veteran's primary risk factor for development of sleep apnea was obesity. The Board has considered the aforementioned VA medical opinions. However, the Board notes that these opinions fail to discuss the fact that the record reflects that the Veteran reported sleep problems as early as January 1987. The March 2010 VA opinion noted that there is no record of sleep apnea while on active duty and the Veteran initially reported onset of apneas several years after discharge. While sleep apnea may not have been diagnosed by a medical professional until much later, it is clear from the medical evidence of record that the Veteran did complain of sleep problems while on active duty. As such, the Board finds that the Veteran should be provided a new VA examination for the proper assessment of her claim. 38 U.S.C.A. § 5103A (West 2002). Thus, this issue must be remanded in order to schedule the Veteran for a VA examination to determine whether she has a current sleep disorder of any kind, to include sleep apnea, that was caused or aggravated by her active duty service. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (if the medical evidence of record is insufficient, the Board is free to supplement the record by seeking an advisory opinion or ordering a medical examination). Additionally, the Board notes that VA has an obligation under VCAA to assist claimants in obtaining evidence, to include relevant records from VA medical care providers. 38 C.F.R. § 3.159 (2011). As such, the Board should take this opportunity to obtain any recent VA treatment records relevant to the Veteran's claim that have not yet been associated with the claims file. Accordingly, the case is REMANDED for the following action: 1. Obtain any and all relevant VA treatment records that have not yet been associated with the claims file. 2. Schedule the Veteran for a VA examination for her claimed sleep apnea or sleep disorder. All appropriate tests and studies should be performed and all clinical findings reported in detail. The claims file should be provided to the appropriate examiner for review, and the examiner should note that it has been reviewed. Additionally, the examiner should elicit from the Veteran a history of symptoms relating to her claimed sleep apnea or sleep disorder. After reviewing the file, examining the Veteran, and noting her reported history of symptoms, the examiner should determine whether the Veteran has sleep apnea or a sleep disorder of any kind. Then, an opinion should be provided as to whether it is at least as likely as not that the Veteran's current sleep apnea or sleep disorder of any kind was caused or aggravated by her active duty service, to include symptoms noted therein. It would be helpful if the examiner would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is a less than 50% likelihood). The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The examiner should provide a complete rationale for any opinions provided. 3. Then, readjudicate the claim on appeal. In particular, review all the evidence that was submitted since the most recent supplemental statement of the case (SSOC) was issued with respect to this claim. If the benefit sought on appeal remains denied, she should be provided a SSOC. After the Veteran has been given the applicable time to submit additional argument, the claim should be returned to the Board for further review. The Veteran 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 or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs