Citation Nr: 1007209 Decision Date: 02/26/10 Archive Date: 03/05/10 DOCKET NO. 08-15 260 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to a rating in excess of 30 percent for a splenectomy and distal partial pancreatectomy, status post adenocarcinoma with sub total resection of the colon with splenic flexure. ATTORNEY FOR THE BOARD D. J. Drucker, Counsel INTRODUCTION The Veteran had active service from October 1969 to November 1972. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. The Board notes that, in November 2009, the Veteran's attorney of record filed a motion to withdraw representation based upon the Veteran's "failure to cooperate" with the attorney in his appeal. The Veteran received a copy of this motion. In February 2010, a Veterans Law Judge at the Board granted the attorney's motion to withdraw from the Veteran's case and the Veteran received a copy of this determination. There is no indication in the record that the Veteran appointed a new attorney or a service organization to represent him in his case on appeal. As such, the Board is of the opinion that all due process requirements were met. During the pendency of the Veteran's case, the United States Court of Appeals for Veterans Claims (Court) recently held that claims for service connection for PTSD encompass claims for service connection for all psychiatric disabilities. Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009) (the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). As such, the Board has recharacterized the Veteran's claim on appeal to more accurately reflect the Court's holding in Clemons. The Veteran's claim of entitlement to service connection for an acquired psychiatric disorder, including PTSD, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's service-connected disability is manifested by a splenectomy. 2. The Veteran's service-connected disability is manifested by distal partial pancreatectomy, status post adenocarcinoma with sub total resection of the colon, which causes daily abdominal pain and diarrhea. CONCLUSIONS OF LAW 1. The criteria for a higher rating for a splenectomy have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 4.117, Diagnostic Code (DC) 7706 (2009). 2. The criteria for a separate 40 percent rating, and not higher, for distal partial pancreatectomy, status post adenocarcinoma with sub total resection of the colon, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 4.114, Diagnostic Codes 7343, 7329, 7347 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act (VCAA) With respect to the claimant's claim, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2009). Prior to the initial adjudication of the claimant's claim, a VCAA letter was sent in June 2006 that fully satisfies the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). In particular, the VCAA notification: (1) informed the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) informed the claimant about the information and evidence that VA will seek to provide; and (3) informed the claimant about the information and evidence that the claimant is expected to provide. An additional letter was sent to the Veteran in November 2008. The claim was readjudicated in a January 2009 supplemental statement of the case. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant notification followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect). VA also fulfilled its duty to obtain all relevant evidence with respect to the issue on appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The claimant's service treatment records, VA medical treatment records, and identified private medical records have been obtained, to the extent available. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. There is no indication in the record that any additional evidence, relevant to the issue decided herein, is available and not part of the claims file. The claimant was also afforded VA examinations in July 2006 and November 2008 to assess the current severity and all manifestations of his service- connected gastrointestinal disability. 38 C.F.R. § 3.159(c)(4). The records satisfy 38 C.F.R. § 3.326. As such, VA has satisfied the duty to assist the Veteran in the development of his claim. The Board may proceed without prejudice to the appellant. In summary, the Board finds that "it is difficult to discern what additional guidance VA could have provided to the veteran regarding what further evidence he should submit to substantiate his claim." Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004); see also Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc) (observing that "the VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims."); Reyes v. Brown, 7 Vet. App. 113, 116 (1994); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (both observing circumstances as to when a remand would not result in any significant benefit to the claimant). Increased Rating The present appeal involves the Veteran's claim his service- connected gastrointestinal disability warrants a higher disability rating. Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service- connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2009). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). In June 2006, the RO received the Veteran's current claim for an increased rating for his service-connected splenectomy disability. He contends that his gastrointestinal disability is productive of chronic, abdominal pain, and bowel changes that cause unpredictable repeated diarrhea. In July 2006, the Veteran underwent VA examination of his intestines. According to the examination report, the examiner reviewed the Veteran's computerized VA medical records. It was noted that, since December 2003, the Veteran was seen several times at primary care clinics and gave a history of exploratory laparotomy due to persistent diarrhea in 1973 with a splenectomy and partial colectomy due to colon carcinoma. He reported having hematochezia, evaluated with fecal occult blood reported as positive, and was referred to the gastroenterology service where he was evaluated in October 2004, but no studies were recommended at that time. The Veteran indicated that he was followed at a VA outpatient clinic where he was examined every six months for routine follow up. Currently, the Veteran denied weight loss, hematochezia, hematemesis, melena or changes in bowel habits. He also denied any nausea or vomiting. There was no history of hospitalization due to abdominal pain, no intestinal obstruction, and no emergency room visits due to intestinal complaints. Further, it was noted that the Veteran currently worked as a heavy equipment operator. Since the surgery, he said that when he ate, he developed severe abdominal pain that caused him to stop operating the machine and go to the bathroom, that occurred once or twice a day, after which he returned to work. The Veteran denied constipation but had diarrhea after eating on a daily basis, three or four times a day, that he described as soft stools that were sometimes watery but had no treatment for it. There was no history of fistula. Objectively, the Veteran was 70 inches tall, weighed 245 pounds, and was described as an obese male in no apparent or acute distress. Examination of his abdomen revealed a midabdominal well-healed scar, with increased peristalsis, and his abdomen was soft and depressible. There was no edema or cyanosis in his extremities. There was no evidence of malnutrition, anemia, or any other debility. The Veteran reported postprandial, diffuse, lower abdominal discomfort that he graded as a 3 on a scale of 1 to 10 that occurred daily, and was relieved with his bowel movement. He received no current medical treatment for his gastrointestinal symptoms. A barium enema was recommended for evaluation, but the Veteran refused the procedure. The diagnosis was colon carcinoma with a status post partial colon resection, splenectomy and partial pancreatectomy in 1973. VA medical records reveal that, in November 2006, the Veteran was hospitalized for evaluation of cardiac arrhythmias, after coming to the emergency room with complaints of chest pains. His history of hematochezia was noted, but he denied abdominal pain or other gastrointestinal symptoms, and a gastrointestinal abnormality was not noted upon examination. He complained of episodes of blood in his stool while hospitalized, but results of a rectal examination were negative. In November 2008, the Veteran underwent another VA examination that was performed by the physician who examined him in July 2006. It was noted that, in January 2007, VA hospitalized the Veteran due to upper gastrointestinal bleeding and he underwent an upper endoscopy reported with severe gastritis and a duodenal ulcer was the source of the bleeding. He continued to complain of post prandial diarrhea daily for which he received no treatment. The Veteran denied nausea, vomiting, and constipation, and reported having persistent diarrhea one to four times daily. He also had mild left lower quadrant intestinal pain several times a day that he described as colicky and crampy and last several minutes at a time. There was no history of ulcerative colitis or other symptoms. The Veteran also denied episodes of abdominal colic, nausea or vomiting, and abdominal distention, consistent with partial bowel obstruction. Objectively, the Veteran was 68 inches tall and weighed 257 pounds. His overall general health was good and there were no signs of weight loss or malnutrition, anemia, abdominal mass, or abdominal tenderness. The examiner indicated that the Veteran was not employed and that his disability severely affected his ability to shop and travel, and moderately affected his ability to do chores, exercise, and participate in sports and recreation. His disability had no affect on his ability to feed, dress, groom, toilet, and bathe himself. The Veteran's service-connected splenectomy and partial pancreatectomy has been evaluated as 30 percent disabling since March 1976 under Diagnostic Code 7706-7329-7343, and is currently evaluated under Diagnostic Code 7706-7343. In the assignment of diagnostic code numbers, hyphenated diagnostic codes may be used. Injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. Diseases will be identified by the number assigned to the disease itself, with the residual condition added, preceded by a hyphen. 38 C.F.R. § 4.27. The original 30 percent rating was assigned for the splenectomy under DC 7706. Since it was initially assigned, the evaluation for the Veteran's service-connected disability under the diagnostic code has changed. Under the rating criteria in effect prior to September 1995, a 30 percent evaluation was assigned for the removal of the spleen to include complications. Under the current rating criteria, a maximum rating of 20 percent is provided for a splenectomy. A note in connection with this diagnostic code provides that complications such as systematic infections with encapsulated bacteria are to be rated separately. 38 C.F.R. § 4.117, Diagnostic Code 7706. In this case, the Veteran's splenectomy has been assigned a 30 percent evaluation, which is in excess of the maximum evaluation provided for this disability under DC 7706. 38 C.F.R. § 4.117, Diagnostic Code 7706. Moreover, a review of the record fails to reveal that the Veteran currently has any complications such as systematic infections with encapsulated bacteria. Therefore, a rating in excess of 30 percent is not warranted under DC 7706. The 30 percent rating currently assigned has been in effect more than 20 years and is protected. See 38 C.F.R. § 3.951. As noted, the 30 percent rating for the Veteran's splenectomy is rated under Diagnostic Code 7706, for hemic and lymphatic residuals. However, the Veteran's service-connected disability also involves residuals affecting the digestive system, i.e., distal partial pancreatectomy and status post adenocarcinoma of the colon with sub total resection of the colon. These conditions are productive of separate and distinct symptomatology, rather than overlapping or duplicative symptomatology. See 38 C.F.R. § 4.14; see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Therefore, the Board must consider whether a separate rating is warranted. Under the current provisions of 38 C.F.R. § 4.114, Diagnostic Code 7343, a 100 percent rating is assignable for malignant neoplasms of the digestive system, exclusive of skin growths. 38 C.F.R. § 4.114, Diagnostic Code 7343. The Note following this regulation indicates that a rating of 100 percent shall continue beyond the cessation of any surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure. 38 C.F.R. § 4.114; Diagnostic Code 7343, including Note (effective July 2, 2001). Six months after discontinuance of such treatment, the appropriate disability rating is to be determined by mandatory VA examination. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of 38 C.F.R. § 3.105(e). If there has been no local recurrence or metastasis, the rating will be made on residuals. The Veteran's service-connected disability involves sub total resection of the colon. Diagnostic Code 7329 provides ratings for resection of the large intestine. Resection of the large intestine with slight symptoms is rated 10 percent disabling. Resection of the large intestine with moderate symptoms is rated 20 percent disabling. Resection of the large intestine with severe symptoms, objectively supported by examination findings, is rated 40 percent disabling. See 38 C.F.R. § 4.114, Diagnostic Code 7329 (2009). The Veteran's service-connected disability also involves distal partial pancreatectomy. Pancreatitis warrants a 10 percent rating if there is at least one recurring attack of typical severe abdominal pain in the past year. A 30 percent rating is warranted for moderately severe pancreatitis, with at least 4-7 typical attacks of abdominal pain per year, with good remission between attacks. A 60 percent rating requires frequent attacks of abdominal pain, loss of normal body weight, and other findings showing continuing pancreatic insufficiency between attacks. 38 C.F.R. § 4.124a, Diagnostic Code 7347. Note 1 following the criteria for DC 7347 directs that abdominal pain in this condition must be confirmed as resulting from pancreatitis by appropriate laboratory and clinical studies. Note 2 following the criteria for DC 7347 directs that following total or partial pancreatectomy, rate under above, symptoms, minimum rating 30 percent. The provisions of 38 C.F.R. § 4.114 indicate that ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive, will not be combined with each other. A single evaluation will be assigned under the diagnostic code that reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. Id. With respect to Diagnostic Code 7329, the Veteran's complaints include daily abdominal pain and diarrhea. The Board accepts the Veteran's self-report of the frequency of his attacks, as reported to the VA examiner in July 2006 and November 2008. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Examination of the abdomen revealed increased peristalsis. This evidence supports a finding of resection of the large intestine with severe symptoms, objectively supported by examination findings, so as to warrant a 40 percent rating. This is the maximum rating available under DC 7329. While the Veteran has frequent attacks of abdominal pain, there is no evidence showing loss of normal body weight and other findings showing continuing pancreatic insufficiency between attacks. He has denied any weight changes and the medical evidence shows that his weight has remained essentially constant, between 245 and 257 pounds. Therefore, a 60 percent rating is not warranted under DC 7347. After careful consideration of all the evidence of record, the Board concludes that a separate rating of 40 percent is warranted under Diagnostic Code 7329. A higher rating is not in order for any period during the appellate term. Evaluations greater than 40 percent are afforded for adhesions of the peritoneum under Diagnostic Code 7301; gastric, duodenal and gastrojejunal ulcers under Diagnostic Codes 7304, 7305 and 7306; gastritis under Diagnostic Code 7307; postgastrectomy syndrome under Diagnostic Code 7308; dysentery and ulcerative colitis under Diagnostic Codes 7322 and 7323; peritonitis under Diagnostic Code 7331; liver conditions under Diagnostic Codes 7311, 7312, and 7345; and hiatal hernia under Diagnostic Code 7346. However, the Veteran has not been diagnosed with any of these conditions due to his service-connected disability and consideration of these codes is not in order. A separate, compensable evaluation could be warranted for a scar that is the residual of the surgical splenectomy. But, again, the required manifestations are not present. To warrant a compensable evaluation, the scar must be of an area of 144 square inches (929 square centimeters) or greater under Diagnostic Code 7802; or unstable, involving frequent loss of covering of skin over the scar under Diagnostic Code 7803; or superficial and painful on examination under Diagnostic Code 7804; or cause limitation of motion of the affected part under Diagnostic Code 7805. See 38 C.F.R. § 4.118 (2009). The VA examination in July 2006 described the Veteran's abdominal scar as well-healed. No limitation of motion attributable to the scar was observed. VA treatment records, and the November 2008 VA examination report, do not describe findings concerning the scar. Resolving doubt in the Veteran's favor, the probative clinical evidence thus warrants the grant of a separate 40 percent evaluation for his service-connected disability under DC 7329. The preponderance of the evidence is against the grant of a separate, compensable evaluation for the residual scar. The Board has also considered whether the Veteran's disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extra-schedular rating is warranted. See 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology, and provide for a greater evaluation for additional or more severe symptoms; thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluations are, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. ORDER Entitlement to a rating in excess of 30 percent under Diagnostic Code 7706 for splenectomy is denied. Entitlement to a separate 40 percent rating, but no higher, under Diagnostic Code 7329 for distal partial pancreatectomy, status post adenocarcinoma with sub total resection of the colon is granted, subject to the laws and regulations governing the award of monetary benefits. REMAND The Veteran also seeks service connection for an acquired psychiatric disorder including PTSD. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (2009); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f) (2009). In a July 2006 written statement that described his alleged stressful events in service, the Veteran said he was attached to the 820 Ord. Co. and was a truck driver who carried water, food, and other supplies to different locations around Qui Nhon. He indicated that, in approximately November or December 1969, a fellow solider probably named Gonzalez died when the jeep he drove hit a land mine. He further indicated that the depot to which he was attached was attacked "on several" occasions. He said he found several dead and mutilated enemy soldiers and Americans during the period from December 1968 to October 1969. The Veteran also reported constant exposure to mortar and rocket fire. The Veteran's service personnel records indicate that he served in the Republic of Vietnam from February 20, 1969 to April 8, 1970, and was assigned to the 820th Ord. Co. from April 1969 to April 1970. These records also show that campaigns in which he participated include the Vietnam Counteroffensive Phase VI, TET 69/Counteroffensive, Vietnam Summer-Fall 1969, and Vietnam Winter-Spring 1970. In a July 2007 response to the RO's request to verify the Veteran's alleged stressful event in service, the U.S. Army and Joint Services Records Research Center (JSRRC) said that it reviewed the Operational Report Lessons Learned (OR-LL) submitted by the United States Army Support Command Qui Nhon for the period ending October 31, 1969. It was verified that, on October 23, 1969, a jeep convoy hit a mine. No casualties were reported and the jeep was destroyed. U.S. Casualty Reports were also reviewed by the JSRRC that did not verify a Gonzalez as being killed by a mine. In a July 2007 formal memorandum, the RO determined that there was a lack of information to verify the Veteran's alleged stressful events. However, the Veteran also reported that his unit was constantly exposed to rocket and mortar fire and it does not appear that any effort was made to verify this alleged stressful event. The Board believes that, in the interest of due process and fairness, the Veteran should be afforded the opportunity to provide a more specific time frame (preferably within a 60-day time frame) for such exposure. If he cannot provide the exact months, if he can provide the season(s), during which he recalled such exposure, efforts may be made to verify his alleged exposure. The Veteran also provided an April 2006 medical opinion from his private internist, R.A.C., M.D., in which she opined that he had PTSD due to military service. If (and only if) the RO determines that any claimed stressor is verified, the RO should arrange for an examination to obtain an opinion as to whether the Veteran has a diagnosis of PTSD in accordance with 38 C.F.R. § 4.125(a) (i.e., under the criteria of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (1994) (DSM-IV)), and as to the likelihood that such a diagnosis is related to at least one verified in-service stressor. Accordingly, the case is REMANDED for the following action: 1. Contact the appellant and request that he provide more specific information regarding his reported stressful events during service: exposure to rocket and mortar fire. This includes supporting details such as the specific location, names of any individuals involved, and time frame during which the claimed incident(s) occurred (preferably within no more than a 60-day time period, or the season(s), for each claimed incident). Advise the appellant that he can also submit "buddy statements" containing verifiable information regarding the events claimed as "stressors" during his military service. Advise the appellant that this information is vitally necessary in order to obtain supportive evidence of the claimed stressful events he experienced; without which, his claim may be denied. 2. With this information, the RO should review the file and prepare a summary of the alleged exposure to rocket and mortar fire while attached to the 820 Ord. Co. from April 1969 to April 1970. This summary must be prepared whether or not the Veteran provides additional information as requested above. This summary, and a copy of his DD Form 214 and all associated service documents, should be sent to the JSRRC (again), or any other appropriate entity to include the Director, National Archives and Records Administration (NARA), requesting that an attempt be made to independently verify the claimed stressor. Such organizations should be requested to research the Veteran's unit records and any to which his unit was closely assigned, in order to obtain further relevant information on the claimed in-service stressor experience. The JSRRC is particularly requested to verify the 820th Ord. Co. exposure to rocket and mortar fire from November 1 to December 31, 1969, and any other 60-day period identified by the Veteran. Copies of unit histories should be provided and associated with the claims file. 3. After receiving a response from JSRRC, or other appropriate entity, the RO/AMC should make another determination as to whether the Veteran was exposed to rocket and mortar fire, as alleged. 4. Then, schedule the Veteran for a VA psychiatric examination. The claims file and a copy of this remand must be made available to and reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted and all clinical findings reported in detail. The examiner must express an opinion as to whether the Veteran meets the criteria for PTSD contained in DSM-IV and, if he meets such criteria, whether PTSD can be related to the stressor(s) reported by him and established as having occurred during active service. Regardless of whether the Veteran is diagnosed with PTSD, the examiner is requested to provide an opinion as to the diagnosis, date of onset, and etiology of any other psychiatric disorder found to be present, i.e., mood disorder, depression, etc. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any currently diagnosed psychiatric disorder had its onset during active service or is related to any in-service disease or injury. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. 5. Finally, readjudicate the Veteran's claim for service connection for an acquired psychiatric disorder, including PTSD. If the claim remains denied, provide the Veteran with a supplemental statement of the case and allow an appropriate time for response. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ______________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs