Citation Nr: 1036596 Decision Date: 09/28/10 Archive Date: 10/05/10 DOCKET NO. 04-25 380 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a residual left shoulder condition. 2. Entitlement to an initial disability evaluation in excess of 70 percent for service-connected posttraumatic stress disorder (PTSD). [The issue of entitlement to payment or reimbursement for the cost of private medical treatment received between January 1, 2003 and January 9, 2003 will be the subject of a separate decision.] REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Shabnam Keyvan INTRODUCTION The Veteran served on active duty from November 1966 to August 1970. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a May 2003 rating decision in which the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida denied service connection for the left shoulder disorder. The Veteran appealed this decision to BVA, and the case was referred to the Board for appellate review. The issue of entitlement to an initial disability rating in excess of 70 percent for the service-connected PTSD is addressed in the REMAND portion of the decision below and is being 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 left shoulder claim has been obtained. 2. There is competent evidence of a nexus between the Veteran's left shoulder disorder manifested by chronic partial subluxation, arthritis, mild impingement syndrome, and mild degenerative changes of the rotator cuff tendon and his service. CONCLUSION OF LAW Resolving reasonable doubt in favor of the Veteran, a left shoulder disorder manifested by chronic partial subluxation, arthritis, mild impingement syndrome, and mild degenerative changes of the rotator cuff tendon was incurred during his period of active service. 38 U.S.C.A. §1110, 1154 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence that claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). As will be explained in further detail in the following decision, the Board finds that the evidence of record supports the grant of service connection for a left shoulder disability. Therefore, the benefit sought on appeal with respect to this claim has been granted in full. Accordingly, regardless of whether the notice requirements of the law have been met in this case, no harm or prejudice to the Veteran has resulted. See, e.g., Mayfield v. Nicholson, 19 Vet. App. 103, 115 (2005); Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92. Law and Analysis Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the injury was incurred in service. 38 C.F.R. § 3.303(d). In order to establish direct service connection for a disorder, there must be (1) medical evidence of the current disability; (2) medical, or in certain circumstances, lay evidence of the in- service incurrence of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled in service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111. History provided by the Veteran of the pre-service existence of conditions recorded at the time of the entrance examination does not, in itself, constitute a notation of a preexisting condition. 38 C.F.R. §§ 3.304(b)(1); Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1995). To rebut the presumption of sound condition under section 1111 of the statute for disorders not noted on the entrance or enlistment examination, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. VAOPGCPREC 3-2003 (July 16, 2003). Clear and unmistakable evidence is a more formidable evidentiary burden than the preponderance of the evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999) (noting that "clear and convincing" burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than clear and unmistakable evidence). It is an "onerous" evidentiary standard requiring that the no- aggravation result be "undebatable." Cotant v. West, 17 Vet. App. 116, 131 (2003) (citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993) (citing Akins v. Derwinski, 1 Vet. App. 228, 232 (1991)) and Vanerson, 12 Vet. App. at 258, 261; id. at 263. (Nebeker, C.J., concurring in part and dissenting in part). Concerning clear and unmistakable evidence that the disease or injury was not aggravated by service, the second step necessary to rebut the presumption of soundness, a lack of aggravation may be shown by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); 38 U.S.C.A. § 1153. A presumption is an assumption of fact resulting from a rule of law which requires such fact to be assumed from another fact or group of facts found or otherwise established in the action. Black's Law Dictionary 1067 (5th ed. 1979). Therefore, where the presumption of sound condition at entrance to service cannot be rebutted, the fact for which the presumption stands - that is, that the veteran was in sound condition at entry to service as to the disability for which he seeks service connection - must be assumed as a matter of law. Accordingly, service connection may not be granted on the basis of aggravation of a preexisting disease or injury in such a case. Rather, where the government fails to rebut the presumption of soundness under section 1111, the Veteran's claim must be considered one for service incurrence or direct service connection. See Wagner, 370 F.3d at 1094, 1096 (indicating that, in cases where the presumption of soundness cannot be rebutted, the effect is that claims for service connection based on aggravation are converted into claims for service connection based on service incurrence). Here, the Veteran maintains that he has a left shoulder disability that did not pre-exist his active duty. [In this regard, the Board notes that, according to the May 2003 rating action, the RO denied the Veteran's claim for service connection for a left shoulder disability on the basis that the injury that he sustained to this joint occurred prior to his active duty and that there was no objective evidence of a worsening of the pre-existing left shoulder disorder during such service.] Although at the October 1966 enlistment examination the Veteran initially marked that he suffered from a painful or trick shoulder, he then crossed this out and changed his response- indicating that he did not in fact suffer from a painful or trick shoulder or elbow. The physician's summary indicates that the Veteran had several maladies upon his enlistment, including "bad teeth" and "frequent headaches," but there is no mention or notation of a shoulder condition. During a January 1968 sick call treatment visit, the Veteran reported that he had injured his left shoulder in a weightlifting accident three years prior. He was diagnosed with chronic subluxation of the left shoulder. An October 1968 clinical record indicates the Veteran was seen due to complaints of instability and pain in his left shoulder. At the examination, the Veteran referenced the pre-service incident during which he experienced pain in his left shoulder while lifting weights. After examining the Veteran and reviewing an X-ray report of his shoulder, the physician's impression (at the October 1968 treatment session) was that the Veteran had a "[l]oose giant capsule [in the left] shoulder and chronic subluxation." He was found unfit for field duty and transferred to another medical unit for fulfillment of his duties. On the Veteran's August 1970 separation examination, the Veteran reported experiencing a painful or trick shoulder condition, and the examiner diagnosed chronic partial subluxation of the left shoulder. The Board acknowledges statements made by the Veteran to his physician pertaining to a left shoulder injury prior to service. However, as previously noted, the Veteran's October 1966 enlistment examination was negative for any complaints, treatment or diagnosis of shoulder pain or a shoulder disability. Clinical evaluation of his upper extremities was shown to be normal, and he had a physical profile of 1 at the time of this examination. See Odiorne v. Principi, 3 Vet. App. 456, 457 (1992) (observing that the 'PULHES' profile reflects the overall physical and psychiatric condition of the Veteran on a scale of 1 (high level of fitness) to 4 (a medical condition or physical defect which is below the level of medical fitness for retention in the military service)). In addition, the Veteran ultimately did not mark that he had or had had a painful or trick shoulder in his October 1966 report of medical history. The only evidence that the Veteran had a shoulder condition prior to service which was subsequently aggravated during service are reports made by the Veteran himself to his physician during various treatment visits in service. However, his enlistment examination report shows he was fit for duty, and prior to the January 1968 sick call treatment visit, wherein he was diagnosed with chronic subluxation of the left shoulder, there is no evidence of treatment for or a diagnosis of a left shoulder disability. Thus, there is no clear and unmistakable evidence that the shoulder condition pre-existed service. Therefore, the presumption of soundness cannot be rebutted, the Board must find that the left shoulder condition did not pre-exist his period of service. The Veteran is presumed to have been sound upon enlistment. Consequently, the Board's analysis must turn to the issue of whether the left shoulder condition was incurred during the Veteran's active service. See Wagner v. Principi, 370 F.3d 1089, 1094-1096 (Fed. Cir. 2004) (indicating that, in cases where the presumption of soundness cannot be rebutted, the effect is that claims for service connection based on aggravation are converted into claims for service connection based on service incurrence), VAOPGCPREC 3-03 (July 16, 2003). In the case of any Veteran who has engaged in combat with the enemy in active service during a period of war, satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, condition or hardships of such service, even though there is no official record of such incurrence or aggravation. Every reasonable doubt shall be resolved in favor of the Veteran. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). "Satisfactory evidence" is credible evidence. Collette v. Brown, 82 F.3d 389, 392 (1996). Such credible, consistent evidence may be rebutted only by clear and convincing evidence to the contrary. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). The provisions of 38 U.S.C.A. § 1154(b) do not establish a presumption of service connection but ease the combat Veteran's burden of demonstrating the occurrence of some in-service incident to which the current disability may be connected. Clyburn v. West, 12 Vet. App. 296, 303 (1999); Caluza v. Brown, 7 Vet. App. 498, 507 (1995). "Section 1154(b) provides a factual basis upon which a determination can be made that a particular . . . injury was incurred . . . in service but not a basis to link etiologically the [injury] in service to the current condition." Cohen v. Brown, 10 Vet. App. 128, 138 (1997) (citing Libertine v. Brown, 9 Vet. App. 521, 524 (1996); Caluza, supra.). Thus, the provisions of section 1154(b) apply only to the second material issue involved in establishing direct service connection, i.e., evidence of the incurrence of a disease or injury in service. With regard to the remaining two material issues involved in a claim for service connection, i.e., whether there is a current disability and whether there is a nexus between the claimed in- service disease or injury and the current disability, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one with the range of probability as distinguished from pure speculation or remote possibility. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. In considering the evidence of record under the laws and regulations set forth above, the Board finds that the record clearly demonstrates that the Veteran currently has a left shoulder disability. Specifically, the April 2004 VA examination report reflects that the Veteran has multiple diagnoses with respect to his left shoulder, to include chronic partial subluxation, arthritis, mild impingement syndrome, and mild degenerative changes of the rotator cuff tendon. Also, in July 2004, the Veteran received outpatient VA treatment for an unstable left shoulder. See e.g. July 2004 VA treatment opinion, by Dr. V.J. Thus, the remaining questions pertaining to service connection are whether the Veteran incurred an injury or disease during his period of service, and whether his current disability is related to such injury or disease. The Veteran maintains that he suffers from a left shoulder disability as a result of his military service. Specifically, he maintains that in September 1968, while serving as a senior corpsman for the 9th Marine Regiment in Vietnam, his platoon was struck by enemy small arms fire and mortar fire. The Veteran explains that, while attempting to assist a wounded Marine, another mortar round exploded directly behind him, and he was forcefully thrown 20-30 feet in the air and landed on his left shoulder and arm. According to the Veteran's statement, he was not immediately medivaced as he did not want to leave his unit without a senior corpsman, and did not begin receiving treatment for his left shoulder until a replacement corpsman arrived several days later. See e.g. Veteran's statement, dated March 2003. The Veteran also submitted a statement from one of his fellow servicemen who served during the same time period and with the same Marine unit the Veteran was assigned to. The statement relayed that the Veteran was injured while serving as the senior corpsman for the 9th Marine Regiment in the Quang Tri Province in Vietnam, a known combat zone. See e.g. March 2004 Statement issued by T.S. The Veteran maintains that he has experienced pain and reduced mobility in his shoulder since service, and the instability and pain has grown progressively worse over the years. With respect to evidence of an in-service incurrence of a disease or injury, the Board acknowledges the Veteran's statements, as well as that of his fellow serviceman, T.S., that the Veteran served in Vietnam. The Veteran's DD 214 reflects his military occupational specialty was that of medical assistant, and that during his period of active service, he earned numerous awards and decorations, including the Combat Action Ribbon, the Vietnam Service Medal with Bronze Star Device, and the Vietnam Campaign Medal with Device for his achievement. The evidence of record also reflects that the Veteran is currently service-connected for post-traumatic stress disorder (PTSD), rated as 70 percent disabling, effective January 25, 2005. In the May 2005 rating decision granting service connection for PTSD, the RO conceded the Veteran's combat-related stressors while serving in Vietnam. The Board finds that the Veteran's own statements that he sustained a left shoulder injury in service constitutes "satisfactory" or credible evidence that is consistent with the circumstances, condition, or hardships of his combat service. Collette, 82 F.3d at 392. His statements regarding his injuries are credible in light of all the evidence of record and are not rebutted by clear and convincing evidence to the contrary. 38 U.S.C.A. § 1154(b). Indeed, the statement issued by the Veteran's fellow serviceman further corroborates his contention that he injured his left shoulder during a combat situation while performing his duties as a senior corpsman with the 9th Marine Regiment in Vietnam. Furthermore, the only evidence to the contrary is the absence of contemporaneous records documenting such injury, which is insufficient to rebut his statements. Accordingly, the Board concludes that the Veteran did sustain a left shoulder injury during service. 38 U.S.C.A. § 1154(b) (West 2002); 38 C.F.R. § 3.304(d). The final issue remaining is whether the Veteran's current left shoulder disability is related to his injury in service. The Board notes that the question is whether these current conditions are at least as likely the result of the injury he sustained in service, as they are the result of another factor or other factors not related to service. 38 C.F.R. § 3.303(d). The Veteran was afforded a VA examination in April 2004 wherein his claims file and medical records were reviewed. After interviewing the Veteran regarding his medical history, conducting a physical examination of the Veteran's left shoulder, and reviewing reports of the November 2003 X-ray and October 2002 MRI of the left shoulder, the examiner diagnosed the Veteran with chronic partial subluxation of the left shoulder, left shoulder arthritis, mild impingement syndrome, and mild degenerative changes of the rotator cuff tendon. The examiner concluded that the Veteran's left shoulder disability was neither caused by his military service, nor permanently aggravated by his military service beyond the natural progression of the left shoulder subluxation which he had developed prior to his military service. He based his opinion on the fact that no direct injury was documented in the Veteran's service treatment records; and on the Veteran's reported history of having injured his shoulder prior to service. With respect to the first line of reasoning, the Board finds the rationale underlying the examiner's opinion to be invalid and inadequate given that the Veteran participated in combat operations while serving in Vietnam, and the Board has already acknowledged that the Veteran's lay testimony is sufficient in establishing the occurrence of an in-service injury. See Libertine v. Brown, 9 Vet. App. 521, 522-23 (1996); Collette v. Brown, 82 F.3d 389 (Fed. Cir. 1996) (under 38 U.S.C.A. § 1154(b), a combat veteran's assertions of an event during combat are to be presumed if consistent with the time, place and circumstances of such service). With respect to his second line of reasoning, the Board notes that the only evidence of such a medical history are references made by the Veteran himself during two treatment consultations while in service. As previously discussed above, the Board is not persuaded that there is clear and unmistakable evidence demonstrating that the Veteran's current left shoulder disability existed prior to service. There is no objective medical evidence to suggest that the Veteran suffered from pain and instability in his shoulder prior to his entrance in service. The Board finds that the basis underlying the April 2004 VA examiner's line of reasoning rests solely on the Veteran's self-reported statements, and does not point to any objective medical evidence to suggest that he did in fact suffer from a left shoulder condition prior to entering active duty. Further, in a June 2004 statement, another one of the Veteran's fellow servicemen who served in the same Marine unit as the Veteran, attests to the fact that the Veteran was not physically impaired prior to a mortar attack which injured his shoulder as a person had to be physically fit to perform the job of a corpsman. See June 2004 Statement of L.B. As the Veteran is presumed to have been in sound condition at the time he entered service, and given the Board's acknowledgment that the Veteran's lay testimony is sufficient to establish the occurrence of an in-service injury, the Board finds the April 2004 VA medical opinion to be of limited probative value. Additional medical evidence includes a July 2004 VA treatment report, wherein the Veteran's primary care physician, Dr. A. A., opined that the Veteran's left shoulder instability was due to a prior traumatic injury sustained in service in Vietnam, and that his present day left shoulder instability is more likely than not due to the injury he sustained in service in Vietnam, after a mortar round exploded behind him throwing him into the air and onto his shoulder. In a subsequent July 2004 VA opinion, Dr. V.J., Chief of Orthopaedic Service, diagnosed the Veteran with an unstable left shoulder. He noted the Veteran's reported in-service injury in 1968, and also referenced an October 2002 VA treatment report wherein the Veteran was seen and evaluated due to complaints of left shoulder pain. During the October 2002 evaluation, Dr. V.J. determined that the Veteran had "global instability in his shoulder post traumatic" basing his diagnosis on the Veteran's reported history as well as his own physical examination of the Veteran In his July 2004 VA opinion, Dr. V.J. also references the lay statement submitted by the Veteran's fellow serviceman, T.S., and finds that this statement "is compatible with an injury that would cause the Veteran's condition." The Board acknowledges that neither Dr. V.J. nor Dr. A.A. reviewed the Veteran's claims file prior to rendering their opinions. However, not reviewing the claims file itself is not a sufficient basis for the Board to assign lesser probative weight to a diagnosis or opinion. See Nieves-Rodriguez v. Peake 22 Vet.App. 295 (2008) (noting that the mere statement that one physician did or did not have access to a claims file is of little use in providing adequate reasons or bases for a decision where the Board fails to explain what information in the claims file was important and necessary for a competent and persuasive medical opinion and why the absence of record review detracts from the probative value of the opinion of a physician). While both physicians based their opinions on the reported history of the Veteran, reliance on a Veteran's statements renders a medical report incredible only if the Board rejects the statements of the Veteran. Coburn v. Nicholson, 19 Vet. App. 427 (2006). The Board may reject a medical opinion that is based on facts provided by the Veteran that have been found to be inaccurate because other facts present in the record contradict the facts provided by the Veteran that formed the basis for the opinion. See Kowalski v. Nicholson, 19 Vet. App. 171 (2005). Here, as discussed above, the Board finds the Veteran reported history of suffering a left shoulder injury during combat operations while in service to be credible. The Board also gives significant weight to his statements in light of his Combat Action Ribbon, his service-connected PTSD, and lay statements submitted by his fellow servicemen which provide further support for the Veteran's contentions. Therefore, the Board finds that the aforementioned opinions were based on a credible history, and thus, are probative in this case. Moreover, in a detailed report dated in July 2010, a private physician, Dr. AMG, noted that she had reviewed the Veteran's claims folder, including the relevant medical records contained therein. In addition, Dr. AMG discussed in detail the Veteran's pertinent medical history, with citations to both specific service treatment records and post-service medical reports. Then, Dr. AMG opined that "it is at least as likely as not that the [V]eteran's in-service injury resulted in a chronic . . . shoulder condition." [The Board acknowledges that the agency of original jurisdiction has not had the opportunity to adjudicate the Veteran's left shoulder claim in light of this additional evidence. However, in a July 2010 statement, the Veteran's representative waived consideration of this medical evidence by the agency of original jurisdiction.] Given that there is ample evidence in this case favorable to the claim, the Board concludes that a remand is not necessary here to obtain another medical opinion to decide the claim as the medical opinions of record are sufficient for that purpose. 38 C.F.R. § 3.159(c)(4); cf. Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (noting that, because it is not permissible for VA to undertake additional development to obtain evidence against an appellant's case, VA must provide an adequate statement of reasons or bases for its decision to pursue such development where such development could be reasonably construed as obtaining additional evidence for that purpose). Thus, in light of the Veteran's lay statements, the statements offered by his fellow servicemen, VA medical opinions issued by Drs. A.A. and V.J., and Dr. AMG's medical opinion, the Board finds that there is at least an approximate balance of positive and negative evidence in this case regarding the issue of whether the Veteran's current left shoulder condition is related to his in-service shoulder injury. Therefore, the Board resolves reasonable doubt in favor of the Veteran and finds sufficient evidence to warrant the grant of service connection for a left shoulder disorder manifested by chronic partial subluxation, arthritis, mild impingement syndrome, and mild degenerative changes of the rotator cuff tendon. 38 U.S.C.A. § 5107(b). ORDER Entitlement to service connection for a left shoulder disorder manifested by chronic partial subluxation, arthritis, mild impingement syndrome, and mild degenerative changes of the rotator cuff tendon is granted. REMAND In a May 2005 rating action, the RO granted service connection for PTSD (70%, effective from January 25, 2005). In November 2005, the Veteran expressed disagreement with the 70% evaluation assigned to his now service-connected PTSD. He seeks a higher disability rating for this disability. However, a statement of the case (SOC) has not yet been issued. Under these circumstances, a remand is required to accord the agency of original jurisdiction an opportunity to provide the Veteran and his representative with an SOC. See Manlicon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: Furnish the Veteran and his representative an SOC regarding the issue of entitlement to an initial disability rating in excess of 70 percent for service-connected PTSD. Only if the Veteran perfects a timely appeal should the claim be certified to the Board and any necessary development should be conducted, to include addressing whether an increased initial disability evaluation is assignable. The Veteran has the right to submit additional evidence and argument on the matter 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 or by the Court 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). ______________________________________________ THERESA M. CATINO Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs