Citation Nr: 0810587 Decision Date: 03/31/08 Archive Date: 04/09/08 DOCKET NO. 97-23 714 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island THE ISSUES 1. Entitlement to service connection for erectile dysfunction secondary to service-connected low back disability. 2. Whether new and material evidence has been presented to reopen a previously denied claim of entitlement to service connection for a stomach disorder. 3. Whether new and material evidence has been presented to reopen a previously denied claim of entitlement to service connection for a bilateral leg and foot disorder. 4. Entitlement to an initial increased disability rating in excess of 10 percent for metatarsalgia of the right foot. 5. Whether a retroactive payment for an award of service connection for a low back disorder was correctly calculated. The issue of whether there was clear and unmistakable error in a REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD Robert E. O'Brien, Counsel INTRODUCTION The veteran had about four months of active service, from February 18, 1980, to June 27, 1980. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the VARO in Providence, Rhode Island, that denied entitlement to the benefits sought. The case was previously before the Board in January 2004 with regard to metatarsalgia of the right foot. For reasons which will be set below, the issue of the veteran's entitlement to service connection for erectile dysfunction is being REMANDED to the RO by way of the Appeals Management Center (AMC), in Washington, D.C. The veteran will be notified as further action is required. The Board also notes that in accordance with the provisions of 38 U.S.C.A. § 7107 and 38 C.F.R. § 20.900(c) (2007), this case has been advanced on the Board's docket for good cause shown. At the hearing before the undersigned in November 2007, the veteran and his representative stated they were no longer pursuing the issue of the veteran's entitlement to an earlier effective date for the grant of service connection for a low back disability. It was stated that issue was being withdrawn at that time "and may be pursued at a later date." FINDINGS OF FACT 1. By rating decision dated in July 1998, service connection for a chronic stomach disorder was denied on the basis that there was no evidence of a chronic stomach disorder during the veteran's short period of active duty for training. The veteran was informed of the denial determination by communication dated in August 1998. A timely appeal did not ensue. 2. The reopened claim for service connection for a chronic stomach disorder was received in July 2001. 3. Evidence received since the 1998 rating decision is not cumulative or redundant of the evidence at the time of the 1990 decision and is directly probative of the issue. 4. Any current stomach disorder is not related to the veteran's several months of active service. 5. The evidence of record with regard to the veteran's metatarsalgia does not provide any indication of the presence of malunion or nonunion of the tarsal or metatarsal bones with moderately severe symptoms. 6. There is no showing that the veteran's award of disability compensation benefits was incorrectly calculated or based on inaccurate rates of payment. CONCLUSIONS OF LAW 1. A July 1998 rating decision that denied entitlement to service connection for a chronic stomach disorder is final. 38 U.S.C.A. § 7105(c) (West 2002). 2. Evidence received since the July 1998 denial of entitlement to service connection for a chronic stomach disorder is new and material, and the claim is reopened. 38 U.S.C.A. §§ 5108, 7105 (West 2002 & Supp. 2007); 38 C.F.R. § 3.156(a) (2007). 3. The criteria for service connection for a chronic stomach disorder are not met. 38 U.S.C.A. §§ 1131, 5103, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2007). 4. The criteria for a disability rating in excess of 10 percent for metatarsalgia of the right foot are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.71a, Code 5279 (2007). 5. The calculation of the award of service-connected disability compensation benefits was validly established. 38 U.S.C.A. §§ 1134, 1114 (West 2002); 38 C.F.R. §§ 3.4, 3.500 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claim Assistance Act of 2000 (VCAA) describes VA's duties to notify and assist claimants in substantiating claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2007). With regard to the claim for service connection for a chronic stomach disorder, in view of the favorable determination of the Board with regard to the question of reopening the claim, a review of the record shows the veteran was not provided with notice of specific evidence needed to reopen claims, as was required by Kent v. Nicholson, 20 Vet. App. 1 (2006). However, the Board is reopening the claim and therefore the Board finds no prejudice to the veteran in the RO's failure to apprise the veteran of the specific evidence needed to reopen the claim. A review of the record with regard to this issue shows that the veteran had a hearing before a decision review officer at the RO in May 2006. He also had the opportunity to provide testimony before the undersigned Veterans Law Judge in November 2007. Transcripts of the hearing proceedings are of record and have been reviewed. Further, the veteran was accorded a special stomach examination by VA in June 2006 and the examiner based on opinion, following review of the entire claims file, as to the etiology of any current peptic ulcer disease, the veteran's diagnosed stomach disorder. With regard to the claim that the award of benefits were not correctly calculated, the Board fins by analogy that this matter is not affected by the VCAA. Specifically, in Dela Cruz v. Principi, 15 Vet. App. 143 (2001), the United States Court of Appeals for Veterans Claims (Court) held that the enactment of the VCAA did not affect matters on appeal when the question has been limited to statutory interpretation. See also Smith v. Gober, 14 Vet. App. 227 (2000) (holding that the VCAA did not affect the issue presented whether if at all statute allows the payment of interest on past due benefits). The Board notes that the veteran was given a thorough discussion as to exactly how the VA calculated the award of benefits in a statement of the case dated in March 2007. With regard to the claim for an increased rating for metatarsalgia, a review of the record shows the case was remanded by the Board in January 2004 for further development. Additional records were obtained and associated with the claims folder. There is no indication of the presence of any records that have not been obtained and associated with the claims folder with regard to this matter. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to timing and content with regard to the increased rating matter. The Board also finds that VA has complied with the VA's duty to assist by aiding the veteran in obtaining evidence and affording him the opportunity to give testimony at an RO hearing in May 2006 and before the undersigned Veterans Law Judge in November 2007. The veteran was accorded a comprehensive examination of the feet by VA in October 2006. The examiner reviewed the entire claims file and specifically discussed the degree of severity of the metatarsalgia. Accordingly, the Board finds that VA has done everything reasonably possible to notify and to assist the veteran and that no further action is necessary to meet the requirements of the VCAA. New and Material Evidence. In July 1998, the RO denied service connection for a chronic stomach disorder. The veteran was given notice of the rating decision by communication dated the following month. He did not timely appeal the denial of benefits for that claimed disorder. Accordingly, the RO decision with regards to a chronic stomach disorder became final. 38 U.S.C.A. § 7105; 38 C.F.R. § 20.1003. Applicable law provides that a claim that is subject to the prior final decision may nevertheless be reopened if new and material evidence is presented or secured. 38 U.S.C.A. § 5108 (West 2002). New and material evidence is defined by regulation (see 38 C.F.R. § 3.156), which VA amended in 2001. The amended version of 38 C.F.R. § 3.156(a) is only applicable to claims filed on or after August 29, 2001. In this case, the veteran submitted his request to reopen the previously denied service connection claim in July 2001. Accordingly, the former version of 38 C.F.R. § 3.156(a) is applicable. In this regard, new and material evidence at the time of the receipt of the claim in July 2000 is defined as follows: New and material evidence means evidence not previously submitted to agency decision makers which bears directly and substantially upon a specific matter under consideration, which is neither cumulative nor redundant, and which by itself or in connection with the evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a) (2000). The credibility of any new evidence is to be presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). Since the 1998 denial, VA has obtained medical evidence, including the report of a VA examination of the stomach in June 2006. The Board finds the report of this examination is new and material as it was not previously before agency decision makers and it speaks to the critical facts and etiology of any current stomach disorder. As such, the previously denied claim is reopened and will be addressed on the merits. Service connection may be granted for disability resulting from personal injury suffered or disease contracted during active military service, or for aggravation of a preexisting injury suffered, or disease contracted, during such service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Service connection may also be granted for disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113; 38 C.F.R. § 3.303(d). Ulcer disease will be presumed to have been incurred in service if manifest to a degree of 10 percent or more within one year following discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131; 38 C.F.R. §§ 3.307, 3.309. The Court has held that for service connection to be awarded, there must be (1) medical evidence of a current disability; (2) medical evidence, or in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury during service; and (3) medical evidence of a nexus between the claimed inservice disease or injury and the present disease or injury. Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006); Disabled American Veterans v. Secretary of Veterans Affairs, 419 F.3d 1317, 1318 (Fed. Cir. 2005); Shedden v. Principi, 318 F.3d 1163 (Fed. Cir. 2004). If the veteran fails to demonstrate any one element, denial of service connection will result. 38 U.S.C.A. § 5107 sets forth the standard of proof applied in decisions and claims for veterans benefits. A veteran will receive the benefit of the doubt when an approximate balance of positive and negative evidence exists. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Thus, when a veteran seeks benefits and the evidence is in relative equipoise, the veteran prevails. Wells v. Principi, 18 Vet. App. 33, 36 (2004). A claim will be denied only if the preponderance of the evidence is against the claim. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Board has thoroughly reviewed all the evidence in the claims folder with regard to the claim for service connection for a stomach disorder. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no to discuss in detail the evidence submitted by the veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). (The Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board discuss it's reasons for rejecting evidence favorable to the veteran). A review of the service medical records reveals that the veteran was seen on one occasion complaining of upset stomach in April 1980. He was given (UNCLEAR) viral syndrome. Mylanta was prescribed. There was no further reference to complaints or findings indicative of the presence of a stomach disorder during the remainder of his several months of active duty for training. The veteran was accorded a special stomach, duodenum, and peritoneal adhesions examination by VA in June 2006. The claims file was reviewed by the examiner. The examiner stated that a review of the records show the veteran was seen at a VA medical facility in March 1998 where he reported having undergone an endoscopic procedure in 1983. He stated that an ulcer was found at that time. Addition was made that prior to 1994, the veteran had been drinking alcohol heavily. (TYPED AS DICTATED). The veteran had recently been seen in June 2004 by a physician for complaints of increased epigastric discomfort. Reference was made to testing in 1998 showing patchy antrum with a positive COO test. The examiner stated that based on review of the claims file, as well as discussion with the veteran, it was quite clear that he had a history of epigastric discomfort secondary to gastroesophageal reflux disease. The examiner stated that since the veteran did not have any symptoms at the time of enlistment physical and he presented to the clinic on a one- time basis only during his several months in service with complaints which apparently resolved with Mylanta because a follow-up visit did not make any mention of continuation of symptoms, it was the examiner's opinion that "it is less likely than not that his present history of peptic ulcer disease is related to the episode in 1980 of stomach upset." In an addendum the following day in June 2006, the examiner stated that "based on the C-file records presented to me and no other findings and complaints related to stomach upset or treatment, it is my opinion that the acid dyspepsia that he [the veteran] presented with in 1980, is less likely than not related to his present diagnosis of peptic ulcer disease." The Board is aware of the veteran's assertions that he has a stomach disorder that is attributable to his active service. However, he is not competent to provide such an opinion of a medical nature between any current medical disorder and his active service, as the evidence does not show that he has the requisite knowledge of medical principles that would allow him to render an opinion on a matter involving medical diagnosis or medical etiology. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The VA examiner who examined the veteran in June 2006 had access to the entire evidence of record and expressed the opinion that there was no causal connection between any current stomach disorder and the veteran's active service. There was no medical opinion of record to the contrary. Accordingly, the Board finds the evidence is against the claim for service connection for a chronic stomach disorder. Increased Rating for Metatarsalgia. Disability ratings are determined by an application of the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule). The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. The Board notes that the Court has distinguished a new claim for an increased rating of a service-connected disability from a case where the veteran expresses dissatisfaction with an initial rating of a disability that has just been service connected. See Fenderson v. West, 12 Vet. App. 119 (1999). In the latter case, VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim. A practice known as a "staged rating." The Court has held that evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. § 4.45. See, in general, DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that the disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. According to the circulation, it is essential that the examination on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to these elements. In addition, the regulations state that the functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. The provisions of 38 C.F.R. § 4.45 state that when evaluating the joints, inquiry will be directed as to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. The intent of the rating schedule is recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to heel injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. During the period currently at issue, the veteran's metatarsalgia has been evaluated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5279. Under that code, a maximum 10 percent rating is for assignment for metatarsalgia, whether unilateral or bilateral. In the alternative, a service-connected foot disorder may be considered under alternative codes. Code 5284, for example, provides for a 10 percent rating when there are injuries to the foot which are moderate in degree. A 20 percent rating is assigned when the foot injuries are moderately severe in degree, while a 30 percent rating is assigned when the foot injuries are severe in degree. Also, in the alternative, Code 5283 provides a 10 percent rating when there is malunion of or nonunion of tarsal or metatarsal bones that are moderate in degree. A 20 percent rating is for assignment when the tarsal or metatarsal bones have malunion or nonunion, moderately severe in degree. The maximum 30 percent rating is assigned when there are tarsal, or metatarsal bones, malunion of, or nonunion of, that are severe in degree. 38 C.F.R. § 4.71a, Code 5283. Other codes for higher ratings when there is acquired flatfoot or acquired claw foot (pes cavus). However, this has not been shown in the veteran's case. The medical evidence for the rating period does not show that the metatarsalgia is productive of a disability picture that would warrant a higher rating than the 10 percent currently in effect. While pain is a critical factor, the Board notes that at the time of evaluation in April 2006, it is noted that despite the fact the veteran had high pain scores, observed absence of pain behavior was noted on functional activities. The examiners specifically stated that the veteran's "observed movements were fluid." The medical evidence of record includes a VA X-ray study of the right foot in March 2000. Only very minimal bony spurring was seen in the posterior aspect of the calcaneus. The bones of the foot were otherwise unremarkable. At the time of a foot examination of the veteran in October 2006, notation was made that an examination of March 2002 had been reviewed. It was stated the veteran had never been hospitalized for a foot disorder and had never undergone any surgery. He also had not ever undergone any cast immobilization. The veteran stated that following his several months of active service he worked in several fields, including auto mechanic repair. He indicated the last time he saw a podiatrist for foot problems was in 2004. Currently, he indicated that he walked 1 miles twice a week. He stated that he had to walk a lot and work also. He was observed to walk briskly in the hallway without any assistive device. His gait and posture were described as normal. He was also able to dress and undress without difficulty. He also got onto the examination table without any difficulty. He was able to walk on heels and toes and fully squat. On examination of the feet, it was stated that he had bilateral flatfoot. Examination of the right foot showed no hind foot valgus deformity. There was no tightening or tenderness of the Achillis. There was no misalignment, hammertoe, or hallux valgus deformity present. There was no pain on manipulation and there were no calluses in the plantar aspect. Mild tenderness in the metatarsal head was noted. It was stated the veteran had not received any orthotic devices. He was not receiving any specific treatment for his feet complaints. The diagnosis was bilateral metatarsalgia with no clinical evidence of arthritis of the foot. The examiner stated there was limitation on prolonged standing, walking, running, or jogging due to discomfort in the feet resulting from the metatarsalgia. The examiner stated, however, that there was no evidence of additional limitation due to pain, weakness, fatigue, lack of endurance as a repetitive motion, incoordination, or flare up. The veteran did not require ambulatory aids and there was no evidence of uneven wear of his shoes. Also, there was no evidence of adverse impact on activities of daily living, personal grooming, hygiene, transportation, or in his current occupation. There was no evidence of any further aggravation or increased severity of the service-connected metatarsalgia. With regard to the notation of new evidence of impact on activities of daily living or current occupation, the Board believes this satisfies the VCAA requirements set forth in Vazquez-Flores v. Peake, No. 05-0355 (U.S. Vet. App. January 30, 2008). While the claimant, under that case, must be notified that, should an increase in disability be found, a disability rating will be determined by applying relative diagnostic codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent, based on the nature of the symptoms of the condition for which disability compensation is being sought, the severity and duration, and their effect upon employment in daily life. The veteran has not been informed of the types of evidence that he could submit demonstrating a worsening or increase in severity of the disability and it's impact on his employment and daily life. However, this has been addressed in the report of the 2006 examination. Further, the veteran has already had two hearings with regard to the issue at hand and he is represented by the Disabled American Veterans, a service organization that is well aware of the pertinent laws and regulations and the ways in which a claimant can ask for higher disability ratings. In Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007), the United States Court of Appeals for the Federal Circuit held that any error by VA in providing notice required by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)(1) is presumed prejudicial, and once an error is identified, the burden shifts to VA to demonstrate that the RO was not prejudicial to the veteran. The Federal Circuit stated that requiring an appellant to demonstrate prejudice as a result of any notice error is inconsistent with the purposes of both the VCAA and VA's uniquely proclaimed benefits systems. Instead, the Federal Circuit held in Sanders that all VCAA notice errors are presumed prejudicial and require reversal unless VA can show that the error did not affect the essential fairness of the adjudication. Due to this, VA must show that the purpose of the notice is not frustrated, such s by demonstrating actual knowledge on the part of the claimant and that a reasonable person could be expected to understand from the notice what was needed. As noted, in this case, the veteran's representative organization, as the leading organization in representing veterans before the Board and it is expected that the representative would make the veteran aware as to exactly what was necessary to substantiate his claim. With the two hearings already held, it is anticipated that the veteran has actual knowledge of what is necessary to substantiate his claim. Accordingly, the Board finds that the notice error did not affect the essential fairness of the adjudication. As noted above, at the time of the 2006 examination, there was no clinical evidence of arthritis in the foot. Additionally, there was no evidence of any functional restriction resulting from the metatarsalgia. Additionally, the veteran was receiving no treatment, did not require ambulatory aids, and gave no evidence of uneven wear of his shoes. It was stated there was no evidence of adverse impact on his activities of daily living. In view of the foregoing, a preponderance of the evidence is against the claim as the Board concludes that a rating higher than 10 percent for the veteran's metatarsalgia is not in order. Whether the Retroactive Payment for Service-Connected Low Back Pain was Calculated Correctly. The rates of disability compensation payable to a veteran are established by law. See 38 U.S.C.A. § 1114. These rates are periodically adjusted by Congress, usually on an annual basis. During the period between the effective date of an award or increased award is provided under 38 U.S.C.A. § 5110, or other provision of law, and the commencement of the period of payment based on such award, an individual entitled to receive monetary benefits shall be deemed to be in receipt of such benefits for the purpose of all laws administered by the Secretary. 38 U.S.C.A. § 5111. A review of the record reveals that the veteran has been in receipt of disability compensation for metatarsalgia of the right foot. It has been rated as 10 percent disabling since August 1, 1996. By rating decision dated in July 2004, service connection for a low back disorder secondary to the right foot, was established. A 10 percent rating was assigned, effective March 8, 2001. The combined disability rating of 20 percent was assigned, effective March 8, 2001. The veteran was provided with a chart showing what he was paid and what he was due as a result of that action. Thereafter, as a result of a decision review officer decision, an earlier effective date for his service-connected low back disorder, was granted, with an effective date of September 22, 1999. Accordingly, the 20 percent rating became effective September 22, 1999. The veteran was provided with another chart showing what he was previously paid for that period and what he was currently due. The payments began the first day of the month following the effective date. Payments are made the beginning of each month for the prior month. There was no indication from a review of the file that the rates of pay used in calculating the veteran's benefits were incorrect, and the Board is not persuaded by the veteran's vague contentions that the amount received for his service-connected impairment has been improperly calculated. A review of the audit reveals no mathematical errors. ORDER Service connection for a chronic stomach disorder is denied. A disability rating in excess of 10 percent for metatarsalgia of the right foot is denied. The retroactive payment of disability compensation benefits for service-connected low back disability was calculated correctly. REMAND With regard to the claims for service connection for erectile dysfunction secondary to service-connected low back disability and for bilateral leg and foot disabilities, additional action is necessary before the Board decides these claims. The evidence of record includes a statement from a foot doctor, Dr. Lloyd T. Bowser, Jr., to the effect that there is a "direct correlation between foot problems and back problems." There was a direct correlation between excessive pronation in ankle, knee, hip and back problems." Also, the veteran has been examined for erectile dysfunction, but the examiner did not provide an opinion as to the possible etiology of his erectile dysfunction. As such, the Board finds that the claims must be REMANDED for additional development of the record pursuant to 38 C.F.R. § 3.159(c)(4). Also, see McClendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the case is REMANDED for the following actions: 1. Contact the veteran and obtain releases for all treatment for erectile dysfunction problems and bilateral lower extremity foot problems since the last records were associated with the claims folder in nearly 2007. Obtain all treatment records available. If records could not be obtained, make proper annotation to the claims folder. 2. Thereafter, schedule the veteran for an orthopedic examination to determine the nature and etiology of current disability involving the lower extremities, including the feet. The examiner should be provided with the claims folder and be instructed to review all pertinent records. The examiner should then state, whether it is at least as likely as not that any current disability involving the lower extremities, including the feet, became during service or as a consequence of some event during service. A detailed rationale, with specific reference to the record, for any opinion expressed should be provided. 3. Arrange for the veteran to undergo a VA genitourinary examination in support of his claim for service connection for erectile dysfunction. The claims folder should be reviewed by the examiner and notation of this should be made in the claims file. Following a thorough evaluation, during which all indicated tests should be performed, the examiner should identify and describe whether or not the veteran has erectile dysfunction. If so, the examiner should state whether it is at least as likely as not that any erectile dysfunction is attributable to the veteran's active service, to include his service-connected low back disability. A complete rationale should be provided for any opinion expressed. 4. Thereafter, VA should readjudicate the claims being remanded. For all denied claims, the veteran and his representative should be provided with a supplemental statement of the case and be given an opportunity to respond thereto. Subsequent to current appellate procedures, the case should then be returned to the Board for further appellate consideration. By this REMAND, the Board intimates no opinion as to any final outcome warranted of the claims being remanded. No action is required of the veteran until he receives further notice. The veteran is apprised of the need to report for any scheduled examination, because failure to do so without good cause could result in denial of his claim. 38 C.F.R. § 3.655. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans Benefits Act of 2003, Pub. L. No. 108-183, § 707(a), (b), 117 Stat. 2651 (2003) (to be codified at 38 U.S.C. §§ 5109B, 7112). ______________________________________________ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs