Citation Nr: 1006574 Decision Date: 02/23/10 Archive Date: 03/02/10 DOCKET NO. 05-04 871 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for degenerative disc disease of the lumbar spine with spinal stenosis (lumbar spine disability). 2. Entitlement to service connection for an acquired psychiatric disorder, including posttraumatic stress disorder (PTSD) and hypochondriacal neurosis. 3. Entitlement to service connection for diabetes mellitus with neuropathy of the feet. 4. Entitlement to service connection for sinusitis. 5. Entitlement to service connection for Meniere's disease. 6. Entitlement to service connection for arthritis of multiple joints. 7. Entitlement to service connection for right shoulder osteoarthritis. 8. Entitlement to a compensable rating for service-connected gout. 9. Entitlement to a compensable rating for service-connected scar of the right tympanic membrane with Eustachian tube dysfunction. 10. Entitlement to a compensable rating for service- connected bilateral hearing loss. 11. Entitlement to an increased rating for service-connected tinnitus. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Helena M. Walker, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1959 to July 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, which denied the benefits sought on appeal. In February 2009, the Veteran appeared and testified at a Travel Board hearing at the Houston RO. The transcript is of record. The Board notes that the Veteran's claim of service connection for a lumbar spine disability was adjudicated as a new and material evidence claim. The RO reopened this claim in the April 2005 rating decision. The Board finds, however, that the Veteran filed a timely notice of disagreement in September 2002 to the August 2002 rating decision initially denying service connection for a lumbar spine disability. As such, the Board will proceed with the claim of service connection for a lumbar spine disability on the merits. In regards to the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder, including PTSD and hypochondriacal neurosis, the Board acknowledges that the Veteran's claim of hypochondriacal neurosis was originally denied in a January 1977 rating decision. He is now, however, currently seeking service connection for an acquired psychiatric disorder, including PTSD, which was not previously adjudicated. Because service connection was not previously denied for PTSD, it must be considered de novo. Boggs v. Peake, 520 F.3d 1330 (2008), see also Ephraim v. Brown, 82 F.3d. 399, 402 (Fed. Cir. 1996). Also, the Board finds that characterization of the Veteran's claim as noted on the cover page of this decision best reflects the issue on appeal and will consider the acquired psychiatric disorder claim on the merits and not on a new and material basis. Before the Board may consider the merits of a previously denied claim, it must conduct an independent review of the evidence to determine whether new and material evidence has been submitted sufficient to reopen a prior final decision. The issue of entitlement to service connection for Meniere's disease, right shoulder disability, lumbar spine disability, and arthritis of multiple joints, and increased rating for bilateral hearing loss and gout 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. All relevant evidence necessary for an equitable disposition of the Veteran's appeal has been obtained. 2. On February 5, 2009, prior to the promulgation of a decision in the appeal, the Board received notification from the appellant that he desired to withdraw his appeal seeking increased rating for service-connected tinnitus. 3. The Veteran is not shown to have diabetes mellitus attributable to his period of active service. 4. The Veteran is not shown to have sinusitis attributable to his period of active service. 5. The Veteran is currently awarded the maximum schedular rating for his service-connected right tympanic membrane scar. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal by the Veteran with respect to the claim of an increased rating for tinnitus have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2009). 2. Diabetes mellitus was not incurred in or aggravated during active service, nor may it be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1154, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2009). 3. Sinusitis was not incurred in or aggravated during active service. 38 U.S.C.A. §§ 1131, 1154, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2009). 4. The criteria for a compensable evaluation for scar of the right tympanic membrane are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.87, Diagnostic Code 6211 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Under 38 U.S.C.A. § 7105 (West 2002), the Board may dismiss any appeal which fails to allege specific error of fact or law in determination being appealed. Except for appeals withdrawn on the record at a hearing, appeal withdrawals must be in writing. 38 C.F.R. § 20.204 (2009). Withdrawal may be made by the appellant or by his authorized representative. 38 C.F.R. § 20.204. At the February 2009 Board hearing, the Veteran withdrew his appeal as to the issues of entitlement to an increased rating for service-connected tinnitus. Accordingly the Board does not have jurisdiction to review the appeal as to this matter, and the issue of entitlement to an increased rating for tinnitus is dismissed. Before addressing the merits of the Veteran's remaining claims on appeal, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2007). The notification obligation in this case was accomplished by way of letters from the RO to the Veteran dated in June 2002, December 2004, March 2005, March 2006, and May 2008. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO also provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. The Board would observe that the Veteran has not been afforded an examination in connection with his claim for service connection for diabetes mellitus and sinusitis. However, the Board also finds that VA is not required to schedule the Veteran for a physical examination regarding his claimed diabetes mellitus and sinusitis because the evidence does not meet the criteria set forth in 38 C.F.R. § 3.159(c)(4). Specifically, there is no credible evidence of an event, injury, or disease in service upon which a current disability may be based. As such, the Board will not remand this claim for a medical examination regarding those two issues. Further, the Veteran and his representative have not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal, and have not argued that any error or deficiency in the accomplishment of the duty to notify and duty to assist has prejudiced him in the adjudication of his appeal. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006). Therefore, the Board finds that duty to notify and duty to assist have been satisfied and will proceed to the merits of the Veteran's appeal. Service connection The Veteran seeks service connection for diabetes mellitus and sinusitis. The Veteran did not have service in the Republic of Vietnam, nor has he contended so. Service connection for VA compensation purposes will be granted for a disability resulting from disease or personal injury incurred in the line of duty or for aggravation of a preexisting injury in the active military, naval or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). There must be competent evidence showing the following: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and a disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247 (1999). Arthritis and diabetes mellitus are deemed to be chronic diseases under 38 C.F.R. § 3.309(a) and, as such, service connection may be granted if the evidence shows that the diseases manifest to a degree of ten percent or more within one year from the date of separation from service. 38 C.F.R. § 3.307. Diabetes mellitus The Veteran essentially contends that his diabetes mellitus is attributable to his period of active duty. Again, the Veteran does not assert that he was ever stationed in the Republic of Vietnam or was exposed to Agent Orange-as such, the Board will not address the regulations regarding presumptive service connection for diabetes mellitus based upon herbicide exposure. The Veteran's service treatment records (STRs) are devoid of any treatment related to high blood glucose or other symptoms associated with diabetes mellitus. The Veteran was first noted to be diagnosed as having diabetes mellitus in November 2000 (there are also notations that he was first diagnosed in 1999)-nearly 25 years following discharge from service. Pertinent post-service treatment records show no finding of a relationship between the Veteran's diabetes mellitus and his service. There is no question that the Veteran is currently diagnosed as having diabetes mellitus. Thus, the essential question before the Board is whether his diabetes mellitus is related to his period of active duty. Upon careful review of the evidence the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for diabetes mellitus. Although the Veteran is currently diagnosed as having diabetes mellitus, there is absolutely no clinical evidence linking it to the Veteran's service, nor was the Veteran diagnosed as having diabetes mellitus within a year of discharge from service. Absent a competent medical opinion linking the Veteran's currently diagnosed diabetes mellitus to service, or a diagnosis of diabetes mellitus within one year of service separation, service connection for diabetes mellitus must be denied on both a direct and presumptive basis. Sinusitis The Veteran contends that he experiences sinusitis attributable to his active duty. The Veteran's STRs, including enlistment and separation medical examinations, are devoid of any treatment related to the Veteran's sinuses. There were no findings of a sinus problem in service. In fact, in a March 1975 radiographic report, the Veteran was noted to have normal maxillary sinuses bilaterally, and the visualized portions of the ethmoid and the frontal sinuses were similarly unremarkable. In December 2003, the Veteran was treated for sinusitis and x-ray evidence revealed paranasal and right maxillary sinusitis. In 2004, he was noted to have acute sinusitis. In March 2005, the Veteran was noted to have right maxillary chronic sinusitis. No treatment records relate any current sinusitis to the Veteran's service. There is no question that the Veteran has a history of sinusitis. Therefore the relevant question before the Board is whether his currently diagnosed sinusitis was caused or worsened by the Veteran's service. The Board has carefully reviewed the evidence of record and finds that the preponderance is against the Veteran's claim of service connection for sinusitis. Although the Veteran has a current diagnosis of sinusitis, there is no clinical evidence of record linking sinusitis to the Veteran's active service. Absent a competent medical opinion linking the Veteran's currently diagnosed sinusitis to service, service connection must be denied. Increased ratings The Veteran contends that his scar of the tympanic membrane is more severely disabling than currently rated. Disability evaluations are determined by the application of the schedule of ratings which is based on average impairment of earning capacity. See 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's disability. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). Where entitlement to compensation has been established and a higher initial disability rating is at issue, the level of disability at the time entitlement arose is of primary concern. See Fenderson v. West, 12 Vet. App. 119 (1999). In Hart v. Mansfield, 21 Vet.App. 505 (2007), however, the Court held that "staged" ratings are appropriate for an increased rating claim in such a case, when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The Rating Schedule provides that tympanic membrane perforations are rated noncompensable under 38 C.F.R. § 4.87a, Diagnostic Code 6211. This means that no compensable evaluation is assignable under the rating schedule. As such, the Board finds that no increased evaluation is warranted under Diagnostic Code 6211. The Veteran's other complaints regarding loss of hearing acuity and dizziness possibly associated with Meniere's disease are addressed in the remand portion of this opinion. Thus, the Veteran's request for an increased rating for scar of the right tympanic membrane with Eustachian tub dysfunction must; therefore, be denied. Staged ratings and extraschedular considerations The Board has considered whether to apply staged ratings pursuant to Hart, but finds that under the circumstances, it is not appropriate. The Veteran does not assert that he is totally unemployable because of his service-connected right tympanic membrane scar, nor has he identified any specific factors which may be considered to be exceptional or unusual in light of VA's schedule of ratings. The Board has been similarly unsuccessful in locating exceptional factors. Specifically, the Veteran has not required frequent periods of hospitalization for treatment of his right tympanic membrane scar. Loss of industrial capacity is the principal factor in assigning schedular disability ratings. See 38 C.F.R. §§ 3.321(a) and 4.1. 38 C.F.R. § 4.1 specifically states, "Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." See also Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992) and Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). Therefore, because there is no evidence of the Veteran requiring frequent periods of hospitalizations due to his right tympanic membrane scar, the Board finds that the noncompensable evaluation currently assigned adequately reflects the clinically established impairment experienced by the Veteran. In the absence of requisite factors, the criteria for submission for assignment of an extraschedular rating for this disability pursuant to 38 C.F.R. § 3.321(b)(1) are not satisfied. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Consequently, the Board will not refer this claim to the Director of Compensation and Pension for extraschedular review. ORDER The appeal with respect to the increased rating claim for tinnitus is dismissed. Service connection for diabetes mellitus is denied. Service connection for sinusitis is denied. A compensable rating for scar of the right tympanic membrane is denied. REMAND Upon preliminary review of the evidence of record, and in light of the VCAA, the Board finds that further evidentiary development is necessary. Service connection Acquired psychiatric disorder The Veteran seeks service connection for an acquired psychiatric disorder, including PTSD and hypochondriacal neurosis. As noted above the Veteran was previously denied service connection for hypochondriacal neurosis, but there has never been adjudication of his PTSD claim and the Board has found that the Veteran's claim is best characterized as entitlement to service connection for an acquired psychiatric disorder, which encompasses both PTSD and hypochondriacal neurosis. The Veteran has contended that he was discharged from service due to a finding of hypochondriacal neurosis. He has maintained that his diagnosis was in error, and his current psychiatric diagnoses most appropriately reflect what he experienced in service. In a March 2004 VA treatment record, the Veteran was found to have major depressive disorder, rule-out PTSD. In April 2004, the Veteran underwent a VA psychiatric examination. The examiner was unable to diagnose the Veteran as having what is now referred to as hypochondriasis. The Veteran's reports and symptoms did not fulfill the full criteria for a diagnosis of PTSD. He was, however, diagnosed as having depressive disorder, not otherwise specified, parasomnia, possible cognitive disorder, and alcohol abuse, in remission. The examiner found that the Veteran's depressive symptoms were episodic and strongly associated with frustrating life circumstances. The examiner, however, did not discuss whether the Veteran's current depression was attributable to his service or the treatment for hypochondriacal neurosis in service. He also has psychiatric diagnoses including depression with anxiety and recurrent depression. Upon preliminary review of the evidence of record, the Board finds that a remand is necessary to properly adjudicate the Veteran's claim of service connection for an acquired psychiatric disorder. The Veteran currently has various diagnoses related to his psychiatric condition, but there is no clinical evidence of record reflecting an opinion as to whether the Veteran's current diagnoses were caused or related to the Veteran's service-specifically his in-service diagnosis of hypochondriacal neurosis. As such, the claim is remanded for another VA examination to be scheduled and an opinion obtained as to whether his current psychiatric diagnoses are in any way related to his in-service diagnosis of hypochondriacal neurosis. Meniere's disease The Veteran contends that he has Meniere's disease attributable to his period of active duty. STRs are devoid of any findings related to Meniere's disease. In an August 2002 private treatment record, the Veteran was diagnosed as having Meniere's disease. In April 2004, the Veteran underwent a VA audiological examination. He was noted to have an in-service eardrum rupture in service. He reported symptoms including dizzy spells that includes nausea and no vomiting. He denied ear infections, ear surgery, severe head injury or exposure to Agent Orange during service. The examiner indicated that it is not at least as likely as not that the Veteran's hearing loss and tinnitus are related to Meniere's disease as Meniere's disease typically requires symptoms including rotary vertigo. The examiner indicated that the Veteran denied rotary vertigo, but he did not address the Veteran's complaints of dizzy spells. As such, the Board finds that another VA examination would be helpful in determining whether the Veteran has any pathology similar to Meniere's disease that is attributable to his period of active duty, or caused or worsened by a service-connected disability. Thus, the claim is remanded for another VA examination to be scheduled and an opinion obtained as to whether the Veteran's complaints of dizzy spells are indicative of Meniere's disease, and if so, whether this is related to service or to a service-connected disability. Right shoulder, lumbar spine, and arthritis of multiple joints The Veteran essentially contends that his right shoulder and back were injured in an airplane accident of the Mediterranean during service. There is no documentation in the Veteran's STRs of any treatment for a right shoulder or back disability. There is a January 1966 record in which the Veteran filed a claim on personal items lost and he incurred that loss "when I ditched at sea off the coast of Greece in Aircraft." There was no further notation regarding any injury as a result of this incident. In a May 1977 post-service treatment record, the Veteran was noted to have chronic problems associated with arthritis- specifically painful wrists and shoulders. In June 1977, the Veteran was noted to complain of pain the in ankles, knees, back, right shoulder, wrists, and knuckles. The impression was generalized arthritis. Of note, this was within one year of service separation as he was discharged in July 1976. Post-service treatment reflect treatment for right shoulder pain with findings including, avascular necrosis of the humeral head, degenerative joint disease of the glenohumeral joint space, hypertrophy of the acromioclavicular joint, diffuse tendinosis of the rotator cuff, rotator cuff syndrome, and degenerative cystic changes of the superolateral humeral head. He has also been assessed as having general osteoarthritis, polyarthritis, not otherwise specified, lumbar disc displacement, gout, not otherwise specified with no acute symptoms, osteonecrosis, and rheumatoid arthritis. Treatment records dated in November 2004 note the Veteran's complaints of morning stiffness and joint swelling with all workup being negative except to degenerative changes. Treatment records also reflect a post-service back injury in 1989 In April 2004, the Veteran underwent a VA examination of the joints. His diagnoses included spondylosis of the lumbar spine without radiculopathy, right rotator cuff tear without subluxation or instability, and limited range of motion in the right shoulder. The examiner found, inter alia, that the Veteran did not have symptoms consistent without gout following service. Another examination that same month found the Veteran had multiple joint arthritis, but it made no reference to whether this was attributable to the Veteran's service or whether it was caused or aggravated by a service- connected disability. A January 2006 VA treatment record noted the Veteran's history of a gout diagnosis and treatment for rheumatoid arthritis, and this was later noted to be seronegative rheumatoid arthritis. Upon review of the evidence of record, the Board finds that a remand is necessary regarding the Veteran's claims of service connection for a right shoulder disability, lumbar spine disability, and arthritis of multiple joints. The Board notes that the Veteran was found to have chronic problems associated with arthritis as early as May 1977. This was indeed within the one year presumptive period under 38 C.F.R. § 3.309, following discharge from the Veteran's service. VA examinations of record do not discuss whether the Veteran's arthritis noted in May 1977 to June 1977 was to a compensable degree of 10 percent or more. Also, the Board notes that the clinical evidence of record appears to be confusing regarding the etiology of the Veteran's joint problems that were initially assessed as gout in service. Thus, the Board also requests a discussion as to whether the Veteran's in-service complaints of joint pain were actually due to arthritis, and/or whether the Veteran was misdiagnosed as having gout. The Board notes that the April 2004 VA examiner found that the Veteran's symptoms noted at discharge from service were not conclusive of gout, that the Veteran had no current symptomatology of gout, and that his complaints now are related to arthritis. The examiner, however, did not indicate whether the Veteran's current arthritis complaints were attributable to the same complaints the Veteran had at discharge and within one year following service separation. As such, the Board finds that another VA examination should be scheduled to determine the level of disability of the Veteran's arthritis findings within one year of service discharge, and a more detailed discussion-including the possibility of a misdiagnosis- regarding the Veteran's service-connected gout and his claimed right shoulder disability, lumbar spine disability, and arthritis of multiple joints. Increased ratings The Veteran contends that his bilateral hearing loss and gout symptoms have worsened since his most recent VA examinations for those issues in April 2004. In April 2004, the VA examiner indicated that gout is usually present as an acute inflammation of a single joint and does not usually present as multiple joint arthralgias as in the Veteran. He also indicated that he was unable to see any "radiographic evidence that can be definitely attributed to gouty arthritis." The Board recognizes that the April 2004 VA examination revealed no definitive findings of gout or its related symptomatology. The Veteran was noted to have arthritis of multiple joints that the examiner found to be unrelated to the service-connected gout. At the Veteran's February 2009 hearing, he reported experiencing symptoms of painful toes. He specifically testified that when he tries to cover his toes to sleep, the sheet bothers his toes. In a June 2006 VA audiology consult, audiometric testing was performed, but Maryland CNC testing for speech discrimination was not performed. As such, the consult cannot be used for rating purposes. Additionally, the Veteran has competently indicated that his hearing acuity has worsened since his last examination. As such, the Board finds that a remand is necessary for a VA examination to be scheduled to determine the current severity of his service-connected bilateral hearing loss and gout. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination with an appropriate specialist to determine the nature and etiology of his acquired psychiatric disorder. The Veteran's claims folder should be made available to the examiner. The examiner is to perform all necessary clinical testing and render all appropriate diagnoses. The examiner should then render an opinion as to whether it is at least as likely as not that the Veteran's currently diagnosed acquired psychiatric disorders had their onset in service. The examiner should specifically address the Veteran's contentions that his hypochondriacal neurosis was misdiagnosed and whether his current symptomatology is in any way related to the finding of hypochondriacal neurosis, or other psychiatric condition, noted in service. The examiner should provide rationale for all opinions given. If the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation. 2. Schedule the Veteran for a VA examination with the appropriate specialist to determine the nature and extent of the Veteran's claimed right shoulder disability, lumbar spine disability, and arthritis of multiple joints, as well as a determination as to the current severity of any gout residuals. The Veteran's claims folder should be made available to the examiner for review. The examiner is to perform all necessary clinical testing and render all appropriate diagnoses. The examiner should answer the following questions: a. The examiner is requested to determine in which joints the Veteran had arthritis in within the first year following service. The examiner should specifically determine whether the Veteran had manifestations of right shoulder and lumbar spine arthritis between July 1976 and July 1977. b. Once the examiner determines in which joints the Veteran had arthritis, he or she should determine by the evidence of record, if possible, to what extent the Veteran's arthritis was disabling by July 1977. c. The examiner should also address, in the event that the Veteran's arthritis is not considered 10 percent disabling, whether the Veteran's current complaints in the joints (including the right shoulder and lumbar spine) are attributable to the complaints noted near the time of the Veteran's discharge from service. The examiner is asked to determine, if possible, as to whether the Veteran's arthritic complaints were possibly mischaracterized as gout. d. The examiner is asked to determine whether the Veteran currently experiences any gout residuals and to what extent he experiences them. The examiner should then render an opinion as to whether it is at least as likely as not that the Veteran's current arthritic complaints, including in his right shoulder and lumbar spine, were caused or worsened by the Veteran's service or a service-connected disability. In regards to the lumbar spine disability, the examiner should also discuss the Veteran's post-service work-related back injury in 1989. All opinions expressed must be supported by complete rationale. If the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation. 3. The Veteran should be afforded an audiological examination to determine the current severity of his bilateral hearing loss, and to determine whether the Veteran currently has Meniere's disease and its relationship to service or a service- connected disability. The Veteran's claims folder should be made available to the examiner for review. The examiner is to perform all necessary clinical testing and render all appropriate diagnoses. The examiner is specifically requested to fully describe the functional effects caused by the Veteran's hearing disability and discuss the etiology of the Veteran's claimed dizziness. If the examiner diagnoses Meniere's disease, or other ear pathology, the examiner should then render an opinion as to whether any currently diagnosed ear pathology is related to the Veteran's service, or caused or aggravated by a service-connected disability. The examiner should provide rationale for all opinions given. If the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation. 4. When the development requested has been completed, the case should be reviewed on the basis of the additional evidence. If the benefits sought are not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case, and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The purpose of this REMAND is to obtain additional evidentiary development and the Board, at this time, does not intimate any opinion as to the merits of the case, either favorable or unfavorable. The Veteran is free to submit any additional evidence and/or argument he desires to have considered in connection with his current appeal. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the Veteran until he is notified. 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. 2009). ______________________________________________ MARK W. GREENSTREET Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs