Citation Nr: 0812137 Decision Date: 04/11/08 Archive Date: 04/23/08 DOCKET NO. 06-33 724 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to an initial compensable disability rating for gastroesophageal reflux disease (GERD), to include claim for ulcer and acid reflux. 2. Entitlement to an initial compensable disability rating for migraines. 3. Entitlement to service connection for endometriosis status post hysterectomy, to include claim for dysplasia and CIN II and III. 4. Entitlement to service connection for seborrheic keratosis, claimed as skin lesions. 5. Entitlement to service connection for sinusitis. 6. Entitlement to service connection for fibrocystic breast disease. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L. B. Yantz, Associate Counsel INTRODUCTION The veteran served on active duty from November 1987 to February 1995 and from February 2003 to February 2005, including service in the Southwest Asia theater of operations during the Persian Gulf War. This matter has come before the Board of Veterans' Appeals (Board) on appeal from a November 2005 rating decision of the Columbia, South Carolina Department of Veterans Affairs (VA) Regional Office (RO), which: (1) granted a noncompensable (i.e., 0 percent) disability rating for gastroesophageal reflux disease (GERD) (to include claim for ulcer and acid reflux), effective February 22, 2005; (2) granted a noncompensable (i.e., 0 percent) disability rating for migraines, effective February 22, 2005; and (3) denied service connection for endometriosis status post hysterectomy (to include claim for dysplasia and CIN II and III), seborrheic keratosis (claimed as skin lesions), sinusitis, and fibrocystic breast disease. The veteran perfected her appeal as to the noncompensable disability ratings assigned as well as to the denial of service connection for the aforementioned disabilities. The veteran testified at a video conference Board hearing before the undersigned Veterans Law Judge in January 2008. A transcript of that hearing is associated with the claims file. From the date of the hearing, the record was held open for 30 days in order to allow for the submission of additional evidence for consideration. In January 2008 and February 2008, the veteran submitted additional evidence with a waiver of initial RO consideration. See 38 C.F.R. § 20.1304 (2007). For reasons explained below, the issues of entitlement to an initial compensable disability rating for migraines, entitlement to service connection for sinusitis, and entitlement to service connection for fibrocystic breast disease 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. The veteran's GERD, to include ulcer and acid reflux, is manifested by constipation, indigestion, heartburn (pyrosis), regurgitation, melena, and abdominal pain. 2. Giving the veteran the benefit of the doubt, competent medical evidence has shown that her endometriosis status post hysterectomy, to include dysplasia and CIN II and III, is causally related to her military service. 3. Giving the veteran the benefit of the doubt, competent medical evidence has shown that her seborrheic keratosis, claimed as skin lesions, is causally related to her military service. CONCLUSIONS OF LAW 1. The criteria for a 10 percent rating for GERD, to include ulcer and acid reflux, have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.114, Diagnostic Code 7346 (2007). 2. Resolving the benefit of the doubt in the veteran's favor, endometriosis status post hysterectomy, to include dysplasia and CIN II and III, was incurred during active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2007). 3. Resolving the benefit of the doubt in the veteran's favor, seborrheic keratosis, claimed as skin lesions, was incurred during active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act (VCAA) The VCAA, codified at 38 U.S.C.A. §§ 5100, 5102, 5103A, 5106, 5107, and 5126, was signed into law on November 9, 2000. Implementing regulations were created, codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326 (2007). The legislation has eliminated the well-grounded claim requirement, has expanded the duty of VA to notify the appellant and the representative, and has enhanced VA's duty to assist an appellant in developing the information and evidence necessary to substantiate a claim. See generally VCAA. Given the disposition reached in this case, the Board finds that VA has met its VCAA duty to assist the veteran in the development of her claims now being resolved on appeal. Entitlement to an initial compensable disability rating for gastroesophageal reflux disease (GERD), to include claim for ulcer and acid reflux. Pertinent Laws and Regulations Disability ratings - in general Disability ratings are assigned in accordance with VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2007). Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4. Specific diagnostic codes will be discussed where appropriate below. When a question arises as to which of two ratings shall be applied under a particular diagnostic code, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2007). The veteran's entire history is reviewed when making disability evaluations. See 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1995). However, where the question for consideration is the propriety of the initial evaluation assigned after the grant of service connection, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of "staged ratings" is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found - this practice is known as "staged ratings." See id. at 126. Specific rating criteria The veteran's GERD, to include ulcer and acid reflux, is currently evaluated as 0 percent disabling under 38 C.F.R. § 4.114, Diagnostic Code 7346 (2007). Diagnostic Code 7346 provides the following levels of disability for hernia, hiatal: 60 percent - Symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 30 percent - Persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. 10 percent - With two or more of the symptoms for the 30 percent evaluation of less severity. Analysis The Board finds that, after resolving all reasonable doubt in the veteran's favor, the veteran's disability picture more nearly approximates the criteria for a 10 percent evaluation under Diagnostic Code 7346. The probative medical evidence consists of VA medical examination reports dated in June 2005 and July 2005. During her June 2005 VA gynecological examination, the examiner noted that a review of the veteran's abdomen/gastrointestinal system revealed symptoms of indigestion, heartburn, hemorrhoids, regurgitation, melena, and abdominal pain. During her July 2005 VA genitourinary examination, the veteran reported that her symptoms can depend upon what she eats and that her reflux is triggered by simple things. She reported daily flares of her symptoms and also stated that she experiences constipation. She said that medications such as Prevacid, Miralax, and Metamucil have helped her symptoms. The VA examiner diagnosed the veteran with gastroesophageal reflux disease and constipation, partially controlled with medications. Personal statements from the veteran herself also indicate that a higher 10 percent disability rating is warranted at this time. During her video conference Board hearing in January 2008, the veteran testified that she is taking Prevacid for her acid reflux and that she still has problems with regurgitation of food. See Video Board Hearing Transcript at page 24. She went on to state that she deals with these problems on a daily basis, and that she takes over-the-counter medications like Tums and Mylanta in addition to the Prevacid. See id. at page 25. Taking all of this evidence into consideration, and noting that the veteran suffers from more than two of the symptoms as required by the 10 percent evaluation (namely recurrent epigastric distress, pyrosis, and regurgitation), the Board finds that the veteran's disability picture more nearly approximates the criteria for a higher 10 percent rating under Diagnostic Code 7346, but no more. The symptomatology to warrant a 30 percent evaluation under the criteria of Diagnostic Code 7346 is not shown in the veteran's case. In this regard, the Board notes that the veteran's symptomatology does not include dysphagia, substernal pain, or arm or shoulder pain, nor does it produce considerable impairment of health as required by the 30 percent evaluation criteria. Based upon these findings, and following a full review of the record, the Board finds that the preponderance of the evidence is against a finding that the veteran's disability picture more nearly approximates a 30 percent evaluation. All things considered, the record as a whole does not show persistent symptoms that equal or more nearly approximate the criteria for a 30 percent evaluation at any time since the effective date of service connection, February 22, 2005. See Fenderson, 12 Vet. App. at 125-26. That is to say, the veteran's GERD, to include ulcer and acid reflux, has been no more than 10 percent disabling since the effective date of her award, so her rating cannot be "staged" because this represents her greatest level of functional impairment attributable to this condition. In summary, for the reasons and bases expressed above, the Board concludes that a 10 percent rating is warranted for GERD, to include ulcer and acid reflux. The benefit sought on appeal is granted to that extent. Entitlement to service connection for endometriosis status post hysterectomy, to include claim for dysplasia and CIN II and III. Pertinent Laws and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2007). In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for a claimed disorder, there must be: (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of the in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Where there is a chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however, remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (2007). This rule does not mean that any manifestations in service will permit service connection. To show chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease entity is established, there is no requirement of evidentiary showing of continuity. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2007). Analysis The claims file includes sufficient medical evidence showing a diagnosis of a current disability. Specifically, during her June 2005 VA gynecological examination, the veteran was diagnosed with cervical dysplasia, CIN II and III, and endometriosis with subsequent partial hysterectomy. In addition, during her July 2005 VA genitourinary examination, the veteran was diagnosed with cervical dysplasia, status post hysterectomy. During her first period of active duty (documented by service medical records), and in response to abnormal PAP tests in service, the veteran underwent a colposcopy, cryotherapy, and a laser cone biopsy in 1992. These procedures led to a diagnosis of severe dysplasia and CIN II and III. In 1994, the veteran underwent a dilation of the cervix and curettement of the endometrium (D&C) and a laparoscopy. These procedures led to a confirmed diagnosis of endometriosis. Between her two periods of active duty (documented in private medical records), in December 2002, the veteran underwent a partial hysterectomy and elected to keep her ovaries. During her second period of active duty (documented by service medical records), the veteran continued to suffer from pelvic pain, irregular bleeding, and other symptoms of endometriosis as well as symptoms of menopause. The Board has determined, based upon the medical evidence set forth above, that the veteran's endometriosis status post hysterectomy (including dysplasia and CIN II and III) constitutes a chronic disease which began in service (prior to her December 2002 partial hysterectomy) and now continues to be symptomatic. Following a full review of the record, and giving the veteran the benefit of the doubt, the Board concludes that service connection for endometriosis status post hysterectomy (including dysplasia and CIN II and III) is warranted. Entitlement to service connection for seborrheic keratosis, claimed as skin lesions. Pertinent Laws and Regulations The laws and regulations pertaining to service connection in general have been set out above and will not be repeated. Service connection may be established for a chronic disability resulting from an undiagnosed illness which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2011. See 38 U.S.C.A. § 1117 (West 2002); 38 C.F.R. § 3.317 (2007). Objective indications of a chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from the VA's Schedule for Rating Disabilities for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. A disability referred to in this section shall be considered service-connected for the purposes of all laws in the United States. 38 C.F.R. § 3.317(a)(2-5) (2007). Signs or symptoms which may be manifestations of an undiagnosed illness include, but are not limited to, fatigue, signs or symptoms involving the skin, headaches, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 C.F.R. § 3.317(b) (2007). Analysis The claims file includes sufficient medical evidence showing a diagnosis of a current disability. Specifically, during her June 2005 VA skin disease examination, the veteran was diagnosed with seborrheic keratosis affecting 5 percent of the back, 5 percent of the abdomen, and 5 percent of the leg, amounting to an involvement of 0 percent of the exposed body and 3 percent of the total body. The veteran's service medical records contain a November 1992 examination report in which the veteran was treated for "several 2-3 cm raised, sharply demarcated lesions on right and left arms." An assessment of "insect bites" was offered by the medical provider, and allergy medication was dispensed. In a June 1999 VA Persian Gulf examination report, it was noted that the veteran first noticed several skin lesions (appearing like 1x1 cm raised dark areas on her right leg and abdominal wall) in April 1991. It was noted that a biopsy was taken of one of these lesions while in service, but no diagnosis was given to the veteran at that time. During her June 2005 VA skin disease examination, as well as during treatment at a private medical facility (Rice Creek Family Medicine), the veteran contended that her skin lesions appeared after returning from service in the Gulf War. During her video conference Board hearing in January 2008, she testified that, while serving in the Persian Gulf, she worked in water purification and was stationed in a portion of the desert where chemicals were released nearby. See Video Board Hearing Transcript at page 14. She went on to testify that she believes that her skin lesions were caused by the chemicals that she came into contact with while stationed in the Persian Gulf. See id. at page 15. The Board has determined, based upon the medical evidence set forth above, that the veteran's seborrheic keratosis, claimed as skin lesions, constitutes a chronic disease which began in service and now continues to be symptomatic. In addition, it is noted that this chronic disability did become manifest to a degree of 10 percent in June 2005. See VA Skin Disease Examination Report, June 2005; see also 38 C.F.R. § 4.118, Diagnostic Code 7806. Following a full review of the record, and giving the veteran the benefit of the doubt, the Board concludes that service connection for seborrheic keratosis (claimed as skin lesions) is warranted. ORDER An initial 10 percent disability rating for gastroesophageal reflux disease (GERD), to include claim for ulcer and acid reflux, is granted, subject to the applicable laws and regulations concerning the payment of monetary benefits. Entitlement to service connection for endometriosis status post hysterectomy, to include claim for dysplasia and CIN II and III, is granted. Entitlement to service connection for seborrheic keratosis, claimed as skin lesions, is granted. REMAND During the pendency of this appeal, on March 3, 2006, the Court issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which 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. The Court held that, upon receipt of an application for a service connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id. at 486. Additionally, this notice must state that a disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id. The notice must also include an explanation of the type of evidence that is needed to establish a disability rating and effective date. Id. Here, the veteran has not received this required notice with regard to her service connection claims on appeal. With regard to the issue of entitlement to an initial compensable disability rating for migraines, the Board notes that service connection has already been granted for this disability, but the veteran was not subsequently provided notice of the type of evidence needed to establish a disability rating and effective date. Id. On remand, the veteran should be provided proper notice under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) that informs her not only about the requirements for establishing her entitlement to increased ratings, but also concerning the downstream issue pertaining to the effective dates for the award of benefits, including an explanation as to the type of evidence that is needed to establish an effective date. Entitlement to an initial compensable disability rating for migraines. The Board notes that the most recent VA examination pertaining to the veteran's migraines took place approximately three years ago, when the veteran was afforded a VA neurological examination in June 2005. Since that time, treatment records dated from August 2005 to July 2007 from the VA Medical Center (VAMC) in Columbia, South Carolina have been associated with the claims file. Notably, the most recent of these records contains a neurologist's impression that the veteran's migraines have worsened. See Columbia VAMC Treatment Record dated July 3, 2007. In addition, during her video conference Board hearing in January 2008, the veteran testified that "a couple of times a month [the migraines] get really, really bad...the kind where basically there's no light, no noise, you just kind of shut yourself in the room for just absolute quiet...I'm real nauseous [during that time]...the pills that I take [do] help me to sleep somewhat." See Video Board Hearing Transcript at pages 19-20. She also stated that she has sought treatment for her migraines in the emergency room at a private hospital (Providence Northeast Hospital) from late 2005 to the present. See id. at pages 16-23. The veteran also testified that she has lost "quite a bit" of time from work due to her migraines and that her employer has made special accommodations in terms of authorizing these days off. See id. at pages 16, 20-23. In February 2008, the veteran submitted evidence from her employer regarding these days missed from work. In view of such evidence, a new VA examination is warranted in order to fully and fairly evaluate the veteran's claim for an initial compensable disability rating for migraines on appeal. Entitlement to service connection for sinusitis. Entitlement to service connection for fibrocystic breast disease. With regard to the veteran's sinusitis, the Board notes that the veteran's testimony during her video conference Board hearing indicated that she was seeking treatment from a VA doctor for her sinusitis as recently as one week before her hearing (in January 2008). See Video Board Hearing Transcript at page 7. On remand, these recent VA treatment records should be obtained and associated with the claims file. With regard to the veteran's fibrocystic breast disease, the Board notes that the RO had previously denied service connection for this condition because the RO did not consider it to be an actually disabling condition. However, during her January 2008 video conference Board hearing, the veteran testified that she might need to have her breasts removed surgically due to the numerous cysts accumulating in her breasts as a result of her disability. See Video Board Hearing Transcript at page 12. According to VA treatment records from the Columbia VAMC, the veteran underwent a mammogram, ultrasound, and breast biopsy during the time period from August 2007 to October 2007; however, because these tests were performed at an outside facility, the results are not contained within the VA treatment records. On remand, these test results should be obtained and associated with the claims file. Upon reviewing all of the evidence of record, the Board feels that the veteran should be afforded the appropriate VA medical examinations in order to determine the nature and etiology of her claimed sinusitis and fibrocystic breast disease. In so doing, the Board must emphasize for the veteran that the Court has also held that the duty to assist "is not always a one-way street" and that, "[i]f a veteran wishes help, [s]he cannot passively wait for it in those circumstances where [s]he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Accordingly, the case is REMANDED for the following actions: 1. The RO should send the veteran and her representative a letter that complies with the notification requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) for all of the claims on appeal. The letter should explain what, if any, information and (medical and lay) evidence not previously provided to VA is necessary to substantiate the claims. The letter should indicate which portion of the evidence, if any, is to be provided by the veteran and which portion, if any, VA will attempt to obtain on her behalf. The letter should also request that the veteran provide any evidence in her possession that pertains to the claims. Finally, the letter should contain an explanation as to the information or evidence needed to establish a disability rating and effective date for the claims on appeal, as outlined by the Court in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). 2. The RO should contact the VAMC in Columbia and request that it provide any records pertaining to the veteran from August 2007 to the present, including the results of any tests performed at outside facilities. Associate this request and all records received with the claims file. If records are unavailable, then a negative reply is requested. 3. The RO should ask the veteran to provide the names, addresses, and approximate dates of treatment of all private health care providers (including Providence Northeast Hospital) who have treated her for her claimed disabilities at any time since departing from active service in 2005. After securing any necessary authorizations, the RO should request copies of all indicated records which have not been previously secured and associate them with the claims folder. If records are unavailable, then a negative reply is requested. 4. After associating with the claims folder all available records received pursuant to Items 1, 2, and 3 above, the veteran should be afforded a VA neurological examination to determine the current nature and severity of her service-connected migraines. Her claims folder should be available to the examiner and reviewed in conjunction with the examination. All indicated tests, studies, and X-rays should be performed. The examiner must determine whether the veteran suffers from characteristic prostrating attacks. If so, then the examiner should characterize the duration, frequency, and severity of such prostrating attacks. A complete rationale for any opinion expressed should be provided. 5. After associating with the claims folder all available records received pursuant to Items 1, 2, and 3 above, the veteran should be afforded the appropriate VA examinations to determine the nature, extent, and etiology of her claimed sinusitis and fibrocystic breast disease. It is imperative that any examiner who is designated to examine the veteran reviews the evidence in the claims folder, including a complete copy of this REMAND, and acknowledges such review in the examination report. All necessary tests should be conducted. Each VA examiner is requested to offer an opinion as to: (a). Does the veteran currently have a sinus and/or breast disorder? If so, state the diagnosis or diagnoses. (b). If the examiner finds that the veteran has a sinus and/or breast disorder, did such disorder(s) have their onset during her periods of active service from November 4, 1987 to February 10, 1995 and/or from February 22, 2003 to February 21, 2005, or were they caused by any incident that occurred during such active service? (c). Did a sinus and/or breast disorder exist prior to the veteran's periods of active duty from November 4, 1987 to February 10, 1995 and/or from February 22, 2003 to February 21, 2005? If so, state (if possible) the approximate date(s) of onset of such disorder(s). (d). If a sinus and/or breast disorder preexisted the veteran's period(s) of active duty, did the disorder(s) increase in disability during such period(s) of active duty? In answering this question, the examiner is asked to specify whether the veteran sustained temporary or intermittent symptoms resulting from service; or whether there was a permanent worsening of the underlying pathology due to service, resulting in any current disability. (e). If a sinus and/or breast disorder increased in disability during service, was that increase due to the natural progression of the disease(s)? (f). If the examiner finds that a sinus and/or breast disorder did not exist prior to the veteran's periods of active duty from November 4, 1987 to February 10, 1995 and/or from February 22, 2003 to February 21, 2005, is it as least as likely as not that such disorder(s) had their onset during service, or were they caused by any incident that occurred during service? (g). With regard to a breast disorder, the examiner should state an opinion as to whether the veteran may need to have one or both breasts surgically removed as a result of such disability. The physician(s) should set forth the complete rationale underlying any conclusions drawn or opinions expressed, to include, as appropriate, citation to specific evidence in the record, in a legible report. A complete rationale should be given for all opinions and should be based on examination findings, historical records, and medical principles. 6. After completion of the foregoing and after undertaking any further development deemed warranted by the record, the RO must readjudicate the veteran's pending claims on the merits. If any determination remains adverse to the veteran, then she and her representative should be furnished with a Supplemental Statement of the Case and should be afforded a reasonable period of time within which to respond thereto. The veteran has the right to submit additional evidence and argument on the matter or matters that 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). ______________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs