Citation Nr: 1334635 Decision Date: 10/30/13 Archive Date: 11/06/13 DOCKET NO. 07-34 322 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for depression. 2. Entitlement to an initial compensable rating for urinary incontinence, for the period from June 27, 2005 to October 16, 2011. 3. Entitlement to an initial rating in excess of 60 percent for urinary incontinence, for the period from October 17, 2011. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Timothy D. Rudy, Counsel INTRODUCTION The Veteran served on active duty from February 1974 to August 1975. This matter comes before the Board of Veterans' Appeals (Board) from a May 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. Subsequently, the Board remanded this matter for additional development in September 2011. During the course of this appeal, in a June 2012 rating decision and supplemental statement of the case, the Veteran's initial disability rating for depression was increased from 10 percent to 50 percent and her initial disability rating for urinary incontinence was increased from noncompensable to 60 percent, effective October 17, 2011. As she has obtained only a partial grant of benefits currently sought on appeal, the issues on appeal are as stated on the title page. The Board has reviewed the claims file and the Virtual VA electronic claims file in connection with this appeal. The higher rating issues for urinary incontinence are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if additional action is required on her part. FINDING OF FACT The evidence does not show that the Veteran's depression results in occupational and social impairment with deficiencies in most areas or total impairment. CONCLUSION OF LAW The criteria for an initial rating in excess of 50 percent for depression are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.125-4.130, Diagnostic Code 9434 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) Before addressing the merits of the higher rating issue on appeal for depression, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and her representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183, (2002). These notice 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 v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor her representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. The Veteran was notified via a letter dated in September 2005 of the criteria for establishing secondary service connection for depression, and her and VA's respective duties for obtaining evidence. Shortly before this appeal was filed, the United States Court of Appeals of Veterans Claims (Court) in Dingess found that the VCAA notice requirements applied to all elements of a claim. An additional notice as to disability ratings and effective dates was not provided to the Veteran; however, this deficiency is not shown to prejudice the Veteran. Because in the decision herein, the Board denies the Veteran's claim for a higher rating for depression, no effective date is being, or will be assigned; accordingly, there is no possibility of prejudice to the Veteran under the notice requirements of Dingess. After the September 2005 correspondence was issued, the Veteran was granted service connection for depression and assigned an initial disability rating and effective date in the rating decision now on appeal. As this claim was more than substantiated in that it was proven, the purpose that the notice is intended to serve has been fulfilled. In addition, since the higher initial rating claim for depression was a "downstream" issue from that of service connection, notice pursuant to the decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), was never required for this issue. See VAOPGCPREC 8-2003 (Dec. 22, 2003). The duty to assist also has been fulfilled as private, VA, and Air Force Base clinic medical records relevant to the Veteran's psychiatric rating claim have been requested or obtained and the Veteran has been provided with adequate VA examinations for her increased initial rating claim. The Board finds that the available medical evidence is sufficient for an adequate determination of this claim. Increased Ratings - Laws and Regulations Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The Court has held that a claim for a higher rating when placed in appellate status by disagreement with the original or initial rating award (service connection having been allowed, but not yet ultimately resolved), remains an "original claim" and is not a new claim for an increased rating. See Fenderson v. West, 12 Vet. App. 119 (1999). In such cases, separate compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the pendency of the appeal, a practice known as "staged" ratings. Id. at 126. It is the responsibility of the rating specialist to interpret 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 present. 38 C.F.R. § 4.2. Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). Evaluation of disabilities based upon manifestations not resulting from service-connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses are prohibited. 38 C.F.R. § 4.14. As a general matter, lay statements are considered to be competent evidence when describing the features or symptoms of an injury or illness. See Falzone v. Brown, 8 Vet. App. 398, 405 (1995). As a layperson the veteran is only competent to report observable symptoms, but not the clinical findings which are applied to VA's Rating Schedule. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Bruce v. West, 11 Vet. App. 405, 410-11 (1998). When there is a question as to which of two evaluations to apply, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating, otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7. The Veteran's depression disability is rated under Diagnostic Code 9434 (2012). Under that code and the General Rating Formula for Mental Disorders, ratings may be assigned ranging between 0 and 100 percent. A 50 percent disability rating requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating requires occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent rating requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. When evaluating a mental disorder, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Reports of psychiatric examination and treatment frequently include a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a GAF scale includes scores ranging between zero and 100 which represent the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. The GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, an assigned GAF score, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). A GAF score of 71 to 80 indicates that if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3. Depresssion Historically, the Veteran was granted service connection for depression in the May 2006 rating decision now on appeal and awarded a 10 percent disability rating, effective June 27, 2005, the date of her claim. In her Notice of Disagreement received in March 2007 the Veteran contended that she felt she was entitled to a higher rating. During the course of her appeal, the disability rating was increased from 10 percent to 50 percent, effective June 27, 2005. The Veteran underwent a VA mental examination in April 2005. According to the report of examination, the Veteran told the examiner that she was a volunteer service specialist at an Ohio Veterans Affairs Medical Center (VAMC) since 1996. She denied being involved in any current outpatient psychiatric treatment and said that she primarily obtained psychiatric treatment through her primary care physician. She also told the examiner that she was very hesitant to see anyone through the VA system due to worries about confidentiality. It was noted that she had seen Dr. C.W. on a one-time basis. It was also noted that she had been prescribed Effexor-XR for the past year and the dosage was raised about a month previously. The examiner noted that she had been prescribed medication in the past for anxiety and sleep. She denied ever being psychiatrically hospitalized and any other individual or group counseling, except for seeing a psychiatrist while in service. The Veteran reported that her mood has fluctuated over the years. It dipped into depressive episodes in which she just sat around and cried while at home for little to no reason. She also had crying episodes at work. She also felt more withdrawn as well as anhedonic. She complained of difficulty concentrating and not caring if she lived or died, but insisted that she was not suicidal. She said that she tried to suppress all feelings of shame and inadequacy. She also claimed that she cycled out of her depression anywhere from a week to a month. She denied ever being hypomanic. While depressed, she complained of significant sleep difficulties. On mental status examination, the Veteran was oriented to person, place, and time and was casually groomed. She denied any delusions or hallucinations and no suicidal or homicidal plans were evident. At times she was mildly tearful. Her memory was intact and there were no severe obsessive or ritualistic behaviors. She reported about one panic attack a year. She complained of difficulty concentrating and said that her anxiety level varied from day to day. She also reported that her crying spells were regular and that she slept erratically at night. Diagnosis was recurrent major depression with a GAF score of 80 assigned. The VA psychiatrist noted that the Veteran had adequate social relationships and that her depression/anxiety was not keeping her from maintaining gainful employment. In a typewritten statement received in September 2005, the Veteran explained that she had not felt like a "complete woman" in 29 years. She said that sometimes she cried at the most awkward times for no reason. To hide her embarrassment, she just went into a room to sit and cry. She said that she was very depressed and confused at times. As a result, she said that she was on medication to suppress her feelings of shame and inadequacy. An April 2006 VA medical record revealed that the Veteran met with a clinical nurse specialist at the VA mental health clinic to discuss treatment options. It was noted that because of the need for confidentiality the Veteran was fearful of seeing a mental health professional. It was also noted that the Veteran was alert and oriented with no evidence of severe problems. She expressed an interest in speaking to someone about stressors in her life, if confidentiality could be maintained. An August 2007 private medical record noted that the Veteran complained of depression and had difficulty sleeping. An inability to concentrate and loss of interest in enjoyable activities also were noted. She denied anxiety, suicidal thoughts, or loss of sexual desire. A January 2008 Air Force base clinic medical record noted that the Veteran had no suicidal ideation and had inquired about switching to Cymbalta as she had better clinical response in the past on this as opposed to Effexor. She showed more energy and was sleeping better. Weaning off Effexor and transitioning to Cymbalta were noted. An euthymic mood also was noted. A March 2008 Air Force base clinic medical record noted that the mental status of the Veteran was normal. Her affect was normal, no disorientation was observed, and her memory was unimpaired. The Veteran underwent a VA PTSD examination in October 2011. The examiner, a VA psychologist, diagnosed the Veteran with both a major depressive disorder and PTSD due to military sexual trauma, or two separate disorders with separate etiologies. The VA examiner explained that it was not possible to differentiate the Veteran's symptoms attributable to each diagnosis because of the overlap between both disorders, such as sleep disturbance, loss of interest, and concentration difficulties. The VA examiner also found that both depression and PTSD appeared to have a very mild impact on the Veteran's overall social and occupational impairment. The examiner noted that no VA mental health records were found in the claims file since the time of the Veteran's last VA examination and that while she took Cymbalta she was not currently seeing a psychologist. The Veteran reported that the longest she saw a counselor post-service was for four to six weeks. The October 2011 VA examiner opined that the Veteran's occupational and social impairment was due to mild or transient symptoms and assigned a GAF score of 80. It was noted that the Veteran had been married a second time post-service for 36 years. She described the marriage as "great" overall, even though the couple had not been intimate for 8 years. She explained to the examiner that she saw the face of her in-service rape perpetrator whenever her husband tried to touch her. She reported feeling an emotional detachment from her husband. She also reported "great" relationships with her biological son, her adopted daughter, and her stepson. She indicated that she frequently spoke with and got together with people outside the home, but did not want to get close to anyone except for family members. She was also an officer in DAV and Amvets and attended their meetings. She was still employed as a voluntary service specialist at an Ohio VAMC and denied any difficulty in performing her job. On mental status examination, the Veteran's psychiatric symptoms included: depressed mood, anxiety, panic attacks that occurred weekly or less often, mild memory loss, and suicidal ideation. The Veteran told the examiner that her mood over the past month had not been very good and that she was "down," and wanted to cry a lot most days. She said that she was sad or blue two to three days per week. She also reported that her depression had been worse in the last five to six years, but she was unaware of a reason for this decline in her mood. Her level of interest in things was low most days and her energy level was reportedly low as well. She got 10 or more hours of sleep per night, but indicated that she had been more fidgety during the past month. She endorsed panic attacks about once a month, feelings of worthlessness, significant weight gain during the past two months, and mild problems with memory, attention and concentration. The Veteran reported suicidal ideation with no plan or intent to follow through. She denied homicidal ideation or hallucinations. Based on the evidence of record, the Board finds that entitlement to a rating in excess of 50 percent for depression is not warranted. The Board has considered the relevant evidence of record and finds that her service-connected depression best approximates the criteria for her current 50 percent rating for occupational and social impairment with reduced reliability and productivity. Initially, the Board observes that the Veteran was diagnosed only with depression in the 2005 VA examination while she was diagnosed with depression and PTSD in the 2011 VA examination. However, the 2011 VA examiner clearly explained that any symptomatology attributable to her nonservice-connected PTSD may be attributed to her service-connected depression. In addition, if the Veteran were service connected for PTSD she would be rated under the same General Rating Formula for Mental Disorders as used to rate her service-connected depression. Since the 2011 VA examiner noted that it was not possible to differentiate the Veteran's depression symptoms from her PTSD symptoms, VA must evaluate her service-connected psychiatric disability as if she were service connected for both depression and for PTSD. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (if VA cannot distinguish by competent medical opinion the extent of symptoms that are attributable to service-related causes from those that are not, VA effectively must presume that all symptoms in question are related to service, i.e., part and parcel of the service-connected disability). In this case, all of the Veteran's psychiatric symptoms for the period since service connection was granted include: depressed mood, anxiety, panic attacks that occurred weekly or less often, mild memory loss, some sleep disturbance, and suicidal ideation. While the Veteran did not endorse all the symptoms that are typically associated with a 50 percent rating for a mental disorder, the Board is not required "to find the presence of all, most, or even some, of the enumerated symptoms." Mauerhan, 16 Vet. App. at 442. What is significant is the severity of the occupational and social impairment due to her symptoms of depression. As noted above, medical personnel have described mild or transient symptomatology and the only assigned GAF score of 80 is consistent with this assessment. In spite of overall mild or transient symptoms the Veteran has been assigned a 50 percent rating, which represents occupational and social impairment with reduced reliability and productivity. Nevertheless, the Board will not upset the initial rating that has been awarded. A higher rating would require occupational and social impairment in most areas of life (70 percent rating) or total occupational and social impairment (100 percent). The Board submits that the evidence since service connection was granted effective June 27, 2005, simply does not show that the Veteran's symptomatology reflects deficiencies in most or all aspects of her life. The evidence of record for this time period does not show that the Veteran's psychiatric symptoms were reflective of the criteria for these higher ratings. While there is evidence of suicidal ideation without plan or intent, there is no objective evidence of persistent hallucinations or delusions, obsessional rituals, illogical speech, near continuous panic affecting the ability to function independently, impaired impulse control, spatial disorientation, neglect of personal appearance and hygiene, grossly inappropriate behavior, a persistent danger of hurting self or others, an inability to perform activities of daily living, disorientation to time or place, or memory loss. In addition, information in the claims file shows that the Veteran enjoys a good relationship with her family and at least one close friend. While the Board recognizes that not all, or even any, of the symptomatology noted in the various rating criteria need be present to justify a particular rating, a review of the evidence of record discloses that the Veteran did not demonstrate occupational and social impairment with deficiencies in most areas of life or total impairment. The Board has considered the Veteran's assertions that her depression warrants a higher rating. She is certainly competent to report that her symptoms are worse, Layno v. Brown, 6 Vet. App. 465, 470 (1994), and the Board cannot find in this appeal that she lacks credibility. However, in evaluating a claim for an increased schedular disability rating for depression, VA must consider the Veteran's symptomatology in reference to the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. Massey v. Brown, 7 Vet. App. 204, 208 (1994). While she is competent to report that her symptoms are worse, the training and experience of medical personnel makes the medical findings found in VA treatment records and VA mental health examinations more probative as to the extent and severity of the disability at issue. See Cromley v. Brown, 7 Vet. App. 376, 379 (1995). Moreover, during the course of her appeal, the Veteran's initial disability rating was increased from 10 percent to 50 percent. Consideration has been given to assigning a staged rating for this claim; however, at no time since service connection was granted for depression has the Veteran's symptoms of depression warranted the assignment of a rating higher than what has been assigned. See Fenderson v. West, 12 Vet. App. 119 (1999). When all the evidence is assembled VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The Board finds that the preponderance of the evidence supports the Veteran's initial rating of 50 percent for depression. Finally, the Veteran's psychiatric disability does not warrant referral for extraschedular consideration. In exceptional cases where schedular evaluations are found to be inadequate, consideration of an extraschedular evaluation is made. 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extraschedular evaluation is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. The Board believes that the rating criteria for a mental disorder are not inadequate in this case; the Veteran simply does not meet the schedular criteria for a 70 percent or 100 percent rating in the time period examined in this appeal. Thus, the Board finds that an initial rating in excess of 50 percent for depression is denied. ORDER Entitlement to an initial rating in excess of 50 percent for depression is denied. REMAND Unfortunately, a remand is required in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claims for higher ratings for urinary incontinence so that she is afforded every possible consideration. VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. 38 U.S.C.A. §§ 5107(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(c) (2012). Considering the Veteran's claims for higher ratings for her service-connected urinary incontinence, the Board notes that the report of the October 2011 VA bladder examination refers to VA medical records dated in April 2011 and September 2011. According to the VA examiner, those records discuss the Veteran's recent urinary incontinence symptoms, including resolution of her incontinence issue for some period of time. The Board's review of the claims file failed to locate these recent VA medical records. No medical records were found on the Veteran's Virtual VA eFolder or in the Veterans Benefits Management System. VA has a duty to obtain all relevant VA and governmental records prior to adjudication of a claim. 38 U.S.C.A § 5103A(c)(3); see Bell v. Derwinski, 2 Vet. App. 611 (1992) (observing that any VA treatment records that have been generated up to and including the date of the Board's decision, whether or not filed in the appellant's claims folder, are in the constructive possession of the Board and must be considered). The Board notes that there are no VA treatment records associated with the claims file dated after April 2010. Thus, the Board finds that on remand the RO/AMC shall try to obtain and associate with the claims file, or the Veteran's eFolder, copies of any outstanding VA treatment records which are pertinent to the Veteran's claims for higher ratings for her service-connected urinary incontinence. The Board's review of the October 2011 VA bladder examination also disclosed that the examiner suspected that the Veteran was exaggerating her degree of incontinence and noted that she told him her incontinence returned about four years before the examination, or in 2007, whereas she allegedly had told medical personnel in the April 2011 visit that her incontinence returned in the spring of 2010. Therefore, after all relevant medical records have been associated with the claims file, the Veteran should be scheduled for another VA examination of her service-connected urinary incontinence disorder. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC shall contact the Veteran and her representative and ask them to specify all private, service, and VA medical care providers who have treated her for her service-connected urinary incontinence disability and whose records are not found within the claims file. After the Veteran has signed any necessary releases, the RO/AMC shall then attempt to obtain and associate with the claims file any records identified by the Veteran that are not already associated with the claims file, in particular any records of treatment or evaluation from Wright Patterson Air Force Base Medical Center, for the period since June 2008, and from the Dayton VAMC, for the period since April 2010. VA and Wright Patterson Air Force Base Medical Center treatment records should be requested whether or not the Veteran responds to the request for information. All attempts to procure records should be documented in the file. If the RO/AMC cannot obtain records identified by the Veteran, a notation to that effect should be inserted in the file. The Veteran and her 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. 2. Following completion of the above, the RO/AMC should afford the Veteran a genitourinary examination, by an examiner who has not previously examined her, if possible, to determine the current severity of her service-connected urinary incontinence disability. The claims folder must be made available to the examiner who should indicate on the examination report that the claims folder was reviewed in conjunction with the examination. Any and all studies, tests and evaluations deemed necessary by the examiner should be performed. A rationale for all opinions expressed should be provided. The examiner should evaluate and discuss the severity of the Veteran's service-connected urinary incontinence disability. The examiner also should comment on any occupational impairment resulting from this disability. 3. Thereafter, the issues on appeal shall be reviewed on the basis of the additional evidence. If the benefits sought are not granted, the Veteran and her representative shall be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. 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). These claims 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. 2012). ______________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs