Citation Nr: 0810311 Decision Date: 03/28/08 Archive Date: 04/09/08 DOCKET NO. 05-24 790 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in No. Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for tinnitus. 2. Entitlement to service connection for coronary artery disease. 3. Entitlement to service connection for hypertension. 4. Entitlement to service connection for chronic obstructive pulmonary disease (COPD). 5. Entitlement to an initial rating in excess of 50 percent for post-traumatic stress disorder (PTSD). 6. Entitlement to a compensable rating for adenocarcinoma of the prostate, status post radiation therapy, to include restoration of a 100 percent rating. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD J. Smith, Associate Counsel INTRODUCTION The veteran served on active duty from April 1967 to April 1970, October 1991 to February 1992, and September 2002 to July 2003. The veteran's claim comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs' (VA) Regional Office (RO) in Little Rock, Arkansas, that denied the benefits sought on appeal. The issues of entitlement to service connection for tinnitus, coronary artery disease, hypertension, COPD, and the increased rating for PTSD 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. FINDINGS OF FACT 1. Service connection for residuals of prostate cancer was granted at a disability rating of 100 percent effective from July 22, 2003, by a October 2003 rating decision; this decision and the notice that accompanied it notified the veteran that he would be afforded a future examination to determine the severity of his service-connected adenocarcinoma of the prostate. 2. The veteran underwent external beam radiation therapy for his condition, and this treatment concluded in June 2004. 3. In a November 2004 rating action, the RO proposed to reduce the veteran's disability rating for adenocarcinoma of the prostate to a noncompensable level; following a wait period exceeding 60 days, this reduction was implemented in an April 2005 rating action, effective July 1, 2005. 4. At the time of the reduction of the veteran's 100 percent disability evaluation for adenocarcinoma of the prostate, the competent evidence of record demonstrated clear improvement of that disability. 5. The competent evidence shows that the veteran's current disability picture related to his status post adenocarcinoma of the prostate includes only minor urinary symptoms. CONCLUSION OF LAW The criteria for a compensable evaluation for the veteran's status post adenocarcinoma of the prostate are not met; the reduction of the rating was proper, and the requirements for restoration or a compensable rating have not been met. 38 U.S.C.A. §§ 1114, 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.105(e), 3.344, 4.1-4.14, 4.115b, Diagnostic Code 7528 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSION Before turning to the merits of the rating reduction for the veteran's status post adenocarcinoma of the prostate, the veteran's representative's allegation of CUE will first be addressed. In a March 2006 statement, the veteran's representative stated that the rating reduction was clearly and unmistakably erroneous because the VA examination report upon which it was based did not indicate that the examiner had reviewed the claims file, and that the examination was too old. Governing regulations provide that CUE is applicable only to previous determinations which are final and binding. See 38 C.F.R. §§ 3.104(a), 3.105. The veteran's representative's allegation of CUE in this case is inapplicable in this instance because he alleges CUE as to the April 2005 rating reduction. The April 2005 rating decision is not yet final because it was appealed. The veteran has not alleged CUE as to any prior final rating decision. As CUE is inapplicable to this appeal, any further discussion of the issue is not necessary. Moreover, the Board finds the veteran's representative's contentions of inadequacies with the July 2004 VA examination are unfounded. As it is only the present level of disability at issue, it is of no consequence that the examiner indicated he had not reviewed the claims file. The Board also finds no inadequacy in the fact that the VA examination was conducted in July 2004 and the rating reduction was effectuated ten months later, particularly given the lack of any subsequent evidence to the contrary of the July 2004 examination findings. The Facts The veteran in this case was diagnosed with prostate cancer in May 2003 and he filed a claim for service connection for this condition in July 2003. In an October 2003 rating decision, the veteran was awarded service connection for prostate adenocarcinoma. He was assigned a 100 percent rating under Diagnostic Code 7528 for malignant neoplasms of the genitourinary system effective July 22, 2003, the date of his claim, as his condition was in a state of active malignancy. Pursuant to the terms of DC 7528, the October 2003 rating decision advised the veteran that six months after the conclusion of treatment for his prostate cancer, a new VA examination would be conducted to review any residual disability and to reassess the rating assigned. The medical record shows that the veteran was treated with external beam radiation therapy for his prostate cancer, and that this treatment ended in June 2004. In a November 2004 rating action, the RO proposed to reduce his disability evaluation to a noncompensable level. Such reduction was accomplished in an April 2005 rating decision and the reduction was effective July 1, 2005. In essence, the veteran received a 100 percent rating for his prostate cancer from July 22, 2003 until July 1, 2005, when his award was reduced to a noncompensable level. The veteran challenges the propriety of the rating reduction. Analysis Before an evaluation for a service-connected disability may be reduced or discontinued, the procedural requirements of 38 C.F.R. § 3.105(e) must be satisfied. Specifically, 38 C.F.R. § 3.105(e) provides that a rating proposing the reduction or discontinuance must be prepared, setting forth all material facts and reasons for the action. Additionally, the RO must advise the veteran of the proposed rating reduction or discontinuance and afford 60 days in which to present additional evidence showing that compensation should be continued at the present evaluation level. Id. If such additional evidence is not received within the 60-day period, the RO is to take final rating action and the award is to be reduced or discontinued as set forth in the proposal. Id. Here, the RO proposed the rating reduction in question in a November 2004 rating action. The veteran was sent a notice letter also dated in November 2004. Such communication fully detailed the proposal to reduce his disability evaluation and apprised him that he had 60 days to submit additional evidence to show that a reduction was not appropriate. No evidence was submitted in response to such notice, and the reduction was implemented in an April 2005 rating decision, effective July 1, 2005. Based on the foregoing, the Board concludes that the procedural requirements regarding proper notification of a proposed rating reduction, as outlined in 38 C.F.R. § 3.105(e), were satisfied here. Therefore, the reduction ordered in the April 2005 rating decision is not deemed improper on the basis of deficient notice. Further regarding rating reductions, the law provides that, when a rating has continued for a long period at the same level (5 years or more), any rating reduction must be based on an examination that is as complete as the examinations that formed the basis for the original rating and that the condition not be likely to return to its previous level. 38 C.F.R. § 3.344(a), (b), (c); Kitchens v. Brown, 7 Vet. App. 320, 324 (1995). A reduction may be accomplished when the rating agency determines that evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. 38 C.F.R. § 3.344(a). However, where a rating has been in effect for less than five years, the regulatory requirements under 38 C.F.R. § 3.344(a) and (b) are inapplicable, as set forth in 38 C.F.R. § 3.344 (c). In such cases 38 C.F.R. § 3.344 (c) states that reexamination disclosing improvement will warrant reduction in rating. In the present case, the veteran's 100 percent rating, reduced to a noncompensable in the April 2005 determination on appeal, had been in effect for less than 5 years. As such, the requirements under 38 C.F.R. § 3.344(a) and (b) do not apply in the instant case. Nevertheless, the Court has held that several general regulations are applicable to all rating reduction cases, without regard for how long a particular rating has been in effect. The Court has stated that certain regulations "impose a clear requirement that VA rating reductions, as with all VA rating decisions, be based upon a review of the entire history of the veteran's disability." Brown v. Brown, 5 Vet. App. 413, 420 (referring to 38 C.F.R. §§ 4.1, 4.2, 4.13). A rating reduction requires an inquiry as to "whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based upon thorough examinations." Brown, 5 Vet. App. at 421. Thus, in any rating-reduction case, not only must it be determined that an improvement in a disability has actually occurred, but also that improvement reflects an improvement under the ordinary conditions of life and work. Based on the considerations set forth above, in most cases the Board's task would be to compare the veteran's symptomatology prior to and as of the effective date of the reduction, to determine whether improvement occurred to justify the rating reduction. However, the instant case presents a unique circumstance. Indeed, under the Diagnostic Code at issue, the 100 percent rating initially awarded was not designed or intended to be a permanent reflection of the veteran's disability picture. Rather, the 100 percent rating which the veteran seeks to have restored was awarded pursuant to Diagnostic Code 7528, for malignant neoplasms of the genitourinary system. That code section affords a single temporary 100 percent evaluation and contains no listing or symptomatology associated with such rating. It was awarded solely because the veteran's condition was in active malignancy and he was undergoing therapeutic treatment. A Note to Diagnostic Code 7528 provides that following the cessation of surgical, X- ray, antineoplastic chemotherapy or other therapeutic procedure, the rating of 100 percent shall continue, with a mandatory VA examination at the expiration of six months. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of 38 C.F.R. § 3.105(e). If there has been no local reoccurrence or metastasis, the disability is to be rated on residuals such as voiding dysfunction or renal dysfunction, whichever is predominant. Accordingly, the assignment of a 100 percent rating under Diagnostic Code 7528 is clearly intended to be temporary in nature. The veteran here actually received that rating for almost 2 years, a period much longer than the 6 months contemplated by the rating code. The code is clear that the 100 percent rating is to be replaced by a rating reflecting residual symptomatology due to a therapeutic procedure, such as radiation treatment. Therefore, the central question for consideration is simply whether the veteran's residual symptomatology warrants a rating in excess of the noncompensable evaluation assigned in the April 2005 rating action. In considering this, the medical record shows that the veteran's external beam radiation therapy was completed in June 2004. In a June 2004 VA treatment note the veteran reported a slow urinary stream. In July 2004 the veteran underwent a VA examination. The examiner noted the veteran had completed a course of radiation therapy and was no longer being treated for prostate cancer. The veteran denied any urinary symptoms. He denied any renal symptoms. No symptoms in either regard were found by the examiner. In a July 2004 VA treatment note the veteran was noted as having "some mild urinary symptoms and an enlarged tender left inguinal lymph node" and had been prescribed an antibiotic. In an August 2004 VA treatment note the veteran denied any voiding complaints, had a good force of stream, had no urgency, dysuria, or hematuria, and complained only of an enlarged lymph node. In a December 2004 VA treatment note the veteran again complained of a slow stream. The VA treatment records also generally reflect various prescriptions noted to be "for prostate." As previously described, the regulation directs that residuals of the veteran's disability are to be rated on either renal dysfunction or voiding dysfunction, whichever is predominant. No renal problems have been noted in the medical record. As for a voiding dysfunction, the next highest rating of 20 percent is warranted only where there is evidence that the disability requires the wearing of absorbent materials which must be changed less than 2 times per day. There is no evidence in the claims file that the veteran wears absorbent materials. Thus, a compensable rating is not warranted based on either a renal dysfunction or a voiding dysfunction. There are no other Code sections for consideration. The Board has considered the applicability of other areas of dysfunction, such as urinary frequency, obstructed voiding, or urinary tract infection, but these are not sufficiently raised by the medical evidence, nor are they contemplated under DC 7528. While acknowledging the veteran's complaints regarding his urinary problems, there is no basis for a rating in excess of the noncompensable rating assigned percent based on those symptoms. In sum, the Note to Diagnostic Code 7528 explicitly instructs the evaluator to rate malignant neoplasms of the genitourinary system at 100 percent only for 6 months and then to rate based on residuals. As discussed in detail, evaluation of the veteran's current residuals warrants no higher than a noncompensable evaluation. Therefore, the RO's action in reducing the initially assigned 100 percent rating to a noncompensable evaluation was proper. Notice and Assistance A VCAA notice, as required by 38 U.S.C. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. See, Pelegrini v. Principi, 18 Vet. App. 112, 119- 120 (2004). However, in this case, the appeal does not arise from adjudication of a claim made by the appellant. Rather it arises from a rating reduction by the RO (the 'AOJ' in this case). Therefore, it arises from action initiated by the RO, not the appellant. A rating reduction requires compliance with particular notification procedures under the law which, similar to the VCAA, require that specific notice be given to the veteran before the adjudication takes place. See 38 C.F.R. § 3.105(e), (i) (2005). Moreover, these procedures require that the veteran be given an opportunity to respond to the proposed action not only to submit evidence relevant to the issue of the reduction but also to request a 'predetermination' hearing. The RO complied with these notification procedures, and the Board finds that this compliance essentially meets the notification requirements of VCAA. Therefore, the Board finds that any defect with respect to the VCAA notice requirement in this case was harmless error for the reasons specified below. First, the Board finds that the timing of the notice requirement was met in this case. As noted above, the regulations governing notice of a proposed reduction, like the VCAA, require that notice be given before the adjudication, and this was done in this case. Specifically, the appellant was given notice of an initial proposed reduction to a noncompensable evaluation in November 2004. The appellant has been provided every opportunity to submit evidence and argument in support of his claim and to respond to VA notices, and he has done so. Therefore, in accordance with Pelegrini, the timing of the notice requirement was met in this case and to decide the appeal would not be prejudicial error to the claimant. Second, the requirements with respect to the content of the VCAA notice were met in this case. VCAA notice consistent with 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; (3) inform the claimant about the information and evidence the claimant is expected to provide; and (4) request or tell the claimant to provide any evidence in the claimant's possession that pertains to the claim. This 'fourth element' of the notice requirement comes from the language of 38 C.F.R. § 3.159(b)(1). In this case, the RO informed the appellant in the November 2004 notice of proposed reduction that he may submit medical evidence to show that the RO should not make the change that it proposed to make in the rating assigned for his service- connected prostate disability. The RO informed him of the best type of evidence to submit. The RO informed him of his right to a hearing. In the attached rating decision proposing the reduction, the RO informed the appellant of the evidence it had considered in reaching its determination and advised him of the rating criteria used to evaluate the degree of disability associated with his prostate disability. Although the notice that was provided to the appellant did not specifically contain the 'fourth element,' the Board finds that the appellant was otherwise fully notified of the need to give to VA any evidence pertaining to the proposed reduction in the rating. In this regard, the RO has explained to the appellant in the letters and rating decision proposing the reduction, as well as in the rating decision reducing the rating and the statement of the case, the reasons for the reduction and the rating criteria required for the different levels of disability and, in so doing, informed him of the evidence that was needed to prevent the reduction. Therefore, as noted above, because each of the four content requirements of a VCAA notice has been fully satisfied in this case, any error in not providing a single notice to the appellant covering all content requirements is harmless error. During the pendency of this appeal, on March 3, 2006, the Court issued a decision in the consolidated appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which discussed the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). The Court held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Id. In this case, elements (1), (2), and (3) are not at issue and in January 2007 the appellant has received appropriate VCAA notice as to elements (4) and (5). Thus, the Board finds that any defect with respect to VCAA notification in this regard has not prejudiced the appellant. In addition, the duty to assist the appellant also has been satisfied in this case. VA has made reasonable efforts to identify and obtain relevant records in support of the appellant's claim. 38 U.S.C.A.§ 5103A(a), (b), (c) (West 2002). Specifically, the RO endeavored to secure and associate with the claims file all evidence the appellant identified as being pertinent to his appeal, including all VA treatment records. VA also endeavored to conduct medical inquiry in an effort to substantiate the appellant's appeal by affording the appellant a VA examination in July 2004. 38 U.S.C.A.§ 5103A(d) (West 2002). The Board finds that VA has done everything reasonably possible to assist him. In light of the above, the Board finds that the facts relevant to this appeal have been fully developed and there is no further action to be undertaken to comply with the provisions of the regulations implementing the VCAA. Therefore, the appellant is not prejudiced as a result of the Board proceeding to the merits of the claim. ORDER A compensable evaluation for the veteran's status post adenocarcinoma of the prostate is not warranted, and the rating reduction from the 100 percent evaluation to a noncompensable evaluation was proper. REMAND Additional development is needed as to the veteran's claims for service connection for tinnitus, coronary artery disease, hypertension, and COPD, as well as his initial increased rating claim for PTSD before adjudication can take place. First, a review of the claims file suggests the absence of documents pertaining to the claims on appeal. The record shows the veteran was discharged from his first period of active duty in April 1970, but there are no VA or private treatment documents of record dated earlier than 1996. Efforts must be made to secure all private medical records and VA records that may exist related to the veteran's claims. 38 C.F.R. § 3.159(c)(1) defines reasonable efforts in obtaining records outside the custody of the federal government as "an initial request for the records, and, if the records are not received, at least one follow-up request." As for federal records, 38 U.S.C. § 5103A(b)(3) requires that VA continue any attempts to get federal records "until the records are obtained unless it is reasonably certain that such records do not exist or that further efforts to obtain those records would be futile." If VA makes reasonable efforts to obtain relevant non-Federal records but is unable to obtain them, or after continued efforts to obtain Federal records concludes that it is reasonable certain they do not exist or further efforts to obtain them would be futile, VA will provide the claimant with oral or written notice of that fact. In such a case, VA must notify the veteran of the identity of the records, the efforts VA made to obtain the records, a description of any further action VA will take on the claim, and notice that the veteran is ultimately responsible for providing the evidence. 38 C.F.R. § 3.159(e)(i)-(iv) (2006). VA must attempt to obtain any outstanding pertinent medical records dated between his April 1970 discharge and 1996. A remand is also required in order to afford the veteran a VA examination for his remaining claims on appeal. In the case of a disability compensation claim, VA's duty to assist includes providing a medical examination or obtaining a medical opinion when necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002); 38 C.F.R. § 3.159(c)(4) (2005). Such an examination or opinion is necessary to make a decision on a claim if all of the lay and medical evidence of record (1) contains competent evidence that the claimant has a current disability, or persistent or recurrent symptoms of disability; and (2) indicates that the disability or symptoms may be associated with the claimant's active military, naval, or air service; but (3) does not contain sufficient medical evidence for VA to make a decision on the claim. Id. As for the veteran's claim for tinnitus, the veteran's service medical records show that he was diagnosed with tinnitus during his final period of active duty in March 2003. In October 2003 the veteran underwent a VA examination, and the examiner stated, "[t]he notes of the service audiogram dated 3/28/03 refer to 'some tinnitus' which [the veteran] did not emphasize on the case history form completed at this facility on 10/1/03. It is a possible that the tinnitus has since resolved." The examiner did not note any complaints of tinnitus during the examination. The medical record is devoid of any mention of tinnitus apart from the October 2003 VA examination. However, the veteran is competent to describe his symptoms and in his July 2003 claim form he stated he has tinnitus. A VA examination is necessary to reconcile the evidence pertaining to a current diagnosis, and to determine whether there is any nexus between any current tinnitus and the service medical records. The Board notes that 38 C.F.R. §§ 3.307(a)(3) and 3.309(a) are for consideration in the presence of a current diagnosis even in the absence of a positive nexus opinion. As for the veteran's claim for coronary artery disease and hypertension, the veteran has a current diagnosis of the conditions most recently documented by a July 2005 VA examination. Service medical records, from April 2003, for example, indicate the veteran had coronary artery disease and hypertension in service. However, there is also evidence that these conditions may have preexisted service. For example, as for his coronary artery disease, in June 1996 the veteran had an abnormal EKG. Testing in December 2001 revealed another abnormal EKG, and documents from the veteran's entry into his third period of active duty reveal evidence of old myocardial infractions. As for his hypertension, reports of medical examinations from May 1984, May 1987, and November 1989 document the existence of hypertension. All of this evidence appears in service medical records from the veteran's service with the Arkansas National Guard, and may or may not indicate the veteran's coronary artery disease and hypertension preexisted service, depending on the character of his duty at the time. The character of his duty and the dates of such duty are critical to determining the analysis required for these claims for service connection. The Board can point to no objective documentation verifying the dates the veteran served in the National Guard or from which dates his service constituted active duty for training or inactive duty for training. This information must be obtained, and a VA examination must be afforded to the veteran to determine whether his current coronary artery disease and hypertension were incurred in or aggravated by service. In July and September 2005 the veteran was afforded VA examinations, but the examination reports do not contain any opinion as to either causation or aggravation for either condition. Moreover, the July 2005 VA examiner specifically indicated he did not review the claims file when preparing the report. As for the veteran's claim for service connection for COPD, the record at present shows the veteran received a diagnosis of COPD in February 2003, toward the end of his third period of active duty. He has a current diagnosis of the condition, most recently documented in a VA examination of October 2003. However, the service medical records associated with the file do not contain an entrance examination from this third period of active duty, and until the Board is satisfied that all of the veteran's National Guard records are of file, the dates and character of his duty status is known, and any outstanding VA or private medical records have been obtained, this claim cannot be adjudicated. Upon completion of such development, VA examination is then necessary to determine whether there is any link between the veteran's current COPD and service. As for the veteran's increased rating claim for PTSD, the Board notes that the veteran's claims file is devoid of any medical evidence pertaining to this condition since the July 2004 VA examination upon which service connection was originally granted. Since that time, the veteran has contended that his PTSD symptoms have worsened, in his December 2005 VA Form 9, for example. The United States Court of Appeals for Veterans Claims (Court) has held that when a veteran alleges that his service-connected disability has worsened since he was previously examined, a new examination may be required to evaluate the current degree of impairment. See Snuffer v. Grober, 10 Vet. App. 400, 403 (1997) (a veteran is entitled to a new examination after a two-year period between the last VA examination and the veteran's contention that the pertinent disability had increased in severity). A VA examination is necessary to ascertain the current level of disability caused by the veteran's PTSD. Accordingly, the case is REMANDED for the following action: 1. Contact the National Personnel Record Center and/or the appropriate service entity and request that (1) it verify the veteran's periods of active duty, active duty for training, and inactive duty for training with the Arkansas National Guard, and (2) forward any and all available service medical records associated with such duty that are not already incorporated in the record. If the dates and character of the veteran's service in the Arkansas National Guard cannot be ascertained, a written statement to that effect should be requested for incorporation into the record. Additionally, request all service medical records from the National Personnel Records Center and associate any such documents not previously of record with the veteran's claim folder. In particular, obtain the veteran's entrance examination for his third period of active duty beginning in September 2002, if possible. If these records are unavailable from this source, attempt to obtain them from the Arkansas National Guard. 2. Ask the veteran to list the VA facilities where he has received treatment since his first discharge from active duty in April 1970, and obtain and associate with the claims file any such records that are not already associated with the file. Also ask the veteran to provide authorization forms necessary to allow the RO to obtain outstanding records of any private treatment since his first discharge from active duty in April 1970 related to the claims on appeal. Thereafter, the RO should attempt to obtain those records. Do not associate duplicate records with the file. 3. Afford the veteran a VA examination as to the following conditions for which the veteran is claiming service connection: a. Tinnitus b. Coronary Artery Disease c. Hypertension d. Chronic obstructive pulmonary disease As for tinnitus, the examiner is requested to review all pertinent records associated with the claims file and offer comments and an opinion addressing whether the veteran currently has tinnitus, and whether it is more likely than not (i.e., probability greater than 50 percent), at least as likely as not (i.e., probability of 50 percent), or less likely than not (i.e., probability less than 50 percent), that any current tinnitus had its onset during service or is in any other way causally related to his active service. As for coronary artery disease, hypertension, and chronic obstructive pulmonary disease, if the development above reveals the veteran was on active duty or active duty for training at the time any of these conditions were first noted in the medical records, or if the development does not reveal the character of his duty status either way, conduct a standard VA examination consistent with the directives for the tinnitus examination above for that condition. If the development above reveals the veteran was on not on active duty, or was on inactive duty for training at the time any of these conditions were first noted in the medical records, conduct a VA examination for that condition as follows: the examiner is requested to review all pertinent records associated with the claims file, particularly service medical records, and offer comments and an opinion as to whether the veteran entered any of his active duty service periods with coronary artery disease, hypertension, and/or COPD. If so, the examiner is requested to indicate whether the coronary artery disease, hypertension, and/or COPD increased in severity during service, and if it did, whether the increase in severity represented a chronic worsening of the disorder or the natural progress of the disorder. If the veteran did not enter service with coronary artery disease, hypertension, and/or COPD the examiner is requested to offer an opinion as to whether the coronary artery disease, hypertension and/or COPD is in any way causally or etiologically related to the symptomatology shown in the service medical records. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Copies of all pertinent records in the veteran's claims file, or in the alternative, the claims file itself, must be made available to the examiner. The veteran is hereby notified that it is his responsibility to report for the examination scheduled in connection with this REMAND and to cooperate in the development of his case. The consequences of failure to report for a VA examination without good cause may include denial of his claim. 38 C.F.R. §§ 3.158, 3.655 (2007). 4. Schedule the veteran for a VA examination in order to determine the current severity of his PTSD. The examiner should identify and completely describe all current symptomatology. The veteran's claims folder must be reviewed by the examiner in conjunction with the examination. Ask the examiner to discuss all findings in terms of the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130 (2007). The pertinent rating criteria must be provided to the examiner. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The veteran is hereby notified that it is his responsibility to report for the examination scheduled in connection with this REMAND and to cooperate in the development of his case. The consequences of failure to report for a VA examination without good cause may include denial of his claim. 38 C.F.R. §§ 3.158, 3.655 (2007). After all of the above actions have been completed and the veteran has been given adequate time to respond, readjudicate his claims. If the claims remain denied, issue to the veteran a supplemental statement of the case, and afford the appropriate period of time within which to respond thereto. 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. 2007). ______________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs