Citation Nr: 1102575 Decision Date: 01/21/11 Archive Date: 01/26/11 DOCKET NO. 07-30 926A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois THE ISSUES 1. Entitlement to an initial disability rating in excess of 70 percent for post-traumatic stress disorder (PTSD) with major depressive disorder. 2. Entitlement to a total disability rating based upon individual unemployability due to service-connected disability. REPRESENTATION Veteran represented by: Vietnam Veterans of America WITNESSES AT HEARING ON APPEAL Veteran and his wife ATTORNEY FOR THE BOARD Heather J. Harter, Counsel INTRODUCTION The Veteran served on active duty from October 1968 to March 1972, with subsequent service in the National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2006 RO decision which granted service connection for PTSD, assigning an initial 10 percent disability rating. During the course of the appeal, the RO granted a 30 percent disability rating in an August 2007 decision, effective as of the initial grant of service connection. The Veteran presented sworn testimony in support of his appeal during a videoconference hearing before the undersigned Veterans Law Judge in September 2008. The Board remanded the appeal in December 2008 for additional evidentiary development. Based upon the new evidence, the Appeals Management Center (AMC) granted a 70 percent disability rating for PTSD, again effective as of the initial grant of service connection. The AMC also granted service connection for major depressive disorder, as part and parcel of the Veteran's PTSD. As this grant, although significant, does not represent a complete grant of the benefit sought upon appeal, the matter has once again been returned to the Board for further appellate review. The issue of entitlement to a total disability rating based upon individual unemployability due to service-connected disability is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the AMC in Washington, DC. FINDINGS OF FACT 1. From February 2003 until May 2009, the evidence of record reflects occupational and social impairment, with deficiencies in most areas. 2. From May 2009, total occupational and social impairment is demonstrated. CONCLUSIONS OF LAW 1. The criteria for an award of a disability rating greater than 70 percent are not met for the period of time from February 2003 until May 2009. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.125, 4.126, 4.130, Diagnostic Codes 9411 and 9434 (2010). 2. A 100 percent schedular disability rating for PTSD with major depressive disorder is warranted beginning in May 2009. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.125, 4.126, 4.130, Diagnostic Codes 9411 and 9434 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran and his representative assert that he is totally disabled by his PTSD with major depressive disorder. They assert that he cannot retain or maintain employment due to PTSD and depression. Duties to notify and assist When an application for benefits is received, VA has certain notice and assistance requirements under the law. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). First, proper notice must be provided to a claimant before the initial VA decision on a claim for benefits and must: (1) inform the claimant about the information and evidence not of record 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 the claimant is expected to provide. Review of the claims file shows that the Veteran was informed of these elements with regard to his claims in letters of March 2003 prior to the initial adjudication of his claim for service connection for PTSD. The VA is also required to inform the Veteran of how the VA assigns disability ratings and effective dates. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). A letter with this information was provided in April 2006. VA medical records, service treatment records, Social Security Administration records, and VA examination reports have been obtained and reviewed in support of the Veteran's claim. As noted above, the Veteran presented sworn testimony in support of his claim during a hearing on appeal. The Veteran and his representative have presented written statements in support of his claims. All relevant records and contentions have been carefully reviewed. The Board therefore concludes that the VA's duties to notify and assist have been met with regard to the matters decided herein. Standard of review Once the evidence has been assembled, it is the Board's responsibility to evaluate the record. 38 U.S.C.A. § 7104(a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Analysis Because the veteran has perfected an appeal as to the assignment of the initial rating for PTSD with major depressive disorder following the initial award of service connection, the VA is required to evaluate all the evidence of record reflecting the period of time between the effective date of the initial grant of service connection until the present. Fenderson v. West, 12 Vet. App. 119 (1999). Since the Veteran's service connection grant was implemented effective in February 2003, this exercise involves a fairly lengthy period of time and a large number of medical records. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. If there is disagreement with the initial rating assigned following a grant of service connection, separate ratings can be assigned for separate periods of time, based on the facts found. Fenderson. Reasonable doubt as to the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Congenital or developmental defects such as personality disorders are not diseases or injuries for the purposes of service connection. 38 C.F.R. § 3.303(c), 4.9. See Winn v. Brown, 8 Vet. App. 510, 516 (1996), and cases cited therein. As service connection is precluded for personality disorders, it follows that VA compensation may not be paid for impairment resulting from personality disorders. Under the governing regulatory rating criteria, PTSD and depression, along with other anxiety disorders, are rated under a "General Rating Formula for Mental Disorders". 38 C.F.R. § 4.130, Diagnostic Codes 9411 and 9434. As amended, the regulation reads, in part: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. [70 percent] Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. [100 percent] 38 C.F.R. § 4.130, Diagnostic Codes 9411 and 9434. The psychiatric symptoms discussed above are not exclusive; they are examples of typical symptoms for the listed percentage ratings. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Put another way, the severity represented by those examples may not be ignored. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2009). All diagnoses of mental disorders must conform to the psychiatric standards set forth in the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDER, Fourth Edition, The American Psychiatric Association (1994), (DSM-IV). 38 C.F.R. § 4.125. The Veteran has been receiving VA medical care for PTSD with major depressive disorder throughout the appeal period. Review of these records reveals that he has taken prescription psychiatric medication and had regular psychotherapy throughout the appeal period. Recurrent complaints in the VA medical records include difficulty sleeping, difficulty concentrating, and irritability. According to various information in the file, the Veteran has been married three times, and has been married to his current wife for about fifteen years. He has a history of remote heroin dependence and more recent alcohol abuse, now in remission. He had a history of multiple jail terms in the 1970s, related to drugs, assault, and battery, by his own report. Although suicidal ideation was present throughout the appeal period, the Veteran's care providers repeatedly addressed the situation by reiterating the Veteran's contract to call the VA prior to taking any sort of action, by reminding him of the 24-hour availability of assistance over the phone, and by reinforcing the non-presence of guns in his home. He has physical problems including chronic obstructive pulmonary disease, heart disease, arthritis, and recently-diagnosed diabetes. Social Security records reveal that that he has been unemployed since prior to 2003 and has been receiving Social Security benefits predicated upon unemployability due to chronic brain syndrome and affective/mood disorders since February 2003. During a general medical VA examination in March 2003, the Veteran was noted to be dysphoric, with restricted affect. His insight and judgment were fair, attention span and concentration were within normal limits. His thought content was devoid of suicidality or psychotic symptoms. The examiner described his PTSD as "mild to moderate," and assigned a Global Assessment of Functioning (GAF) Score of 55. VA psychiatric treatment reports throughout the remainder of 2003 reflect GAF Scores of 55. In February 2004, VA hospital reports show that the Veteran attempted to commit suicide by drinking whiskey and taking an overdose of prescription medication, after discovering that his wife was cheating on him. After voluntary admission to the psychiatry unit, the Veteran denied having any suicidal ideation and stated that he would not have tried to kill himself if he had not been intoxicated. He also explained that he did not believe he had an alcohol problem and that he did not want treatment for alcohol abuse. He was determined to be no longer suicidal and was discharged from the hospital following an overnight stay. A GAF Score of 35 was assigned following his initial assessment upon admission to the hospital. Upon transfer to the psychiatry unit, a GAF Score of 47 was assigned. A GAF Score of 50 was assigned upon discharge from the hospital. Subsequent VA treatment reports reflect that the Veteran and his wife were seeking individual and marital counseling. A February 2004 note reflects that the Veteran had had his hair cut after a long time, after he had realized that he had been using his long hair as a way to keep people away from him. A December 2004 note shows that the veteran reported using alcohol rarely, that his last drink had been more than a month prior, and that he did not get intoxicated. An April 2005 VA mental health note reflects that the Veteran was experiencing good symptom control with his medication regimen and that he was doing well and continued to be married. A GAF Score of 65 was assigned. During a VA psychiatric examination in March 2006, he reported frequent nightmares about Vietnam, constant thoughts about Vietnam to the point where he could just be observing the pattern of the linoleum on the floor and he would be taken back to the jungles of Vietnam in his mind. He reported daily problems with suicidal thoughts, although no current plan for suicide. He explained that he had previously been experiencing periods of confusion with dizziness, forgetfulness, and occasional black- outs, but that these episodes had improved after the placement of a cardiac stent and other medical treatment for heart problems. Again, the examiner noted that his thought content was positive for suicidal ideation, but that there was no intention or plan. No homicidal ideation or psychotic symptoms were noted. The examiner rendered diagnoses of recurrent major depressive disorder, in partial remission; alcohol dependence, in partial remission; polysubstance abuse, in full sustained remission; and mild post-traumatic stress disorder. Cluster B personality traits were noted, as well. The examiner assigned a GAF Score of 60, but explained that the majority of the Veteran's reduction in functioning was secondary to his personality traits and his recurrent major depressive disorder. Records of Vet Center therapy sessions between 2005 and 2008 reflect discussions of multiple issues, including the Veteran's marriage and kids, his attempts to quit smoking, dealing with nightmares, and issues involving financial stress. Several notations are to the effect that the Veteran was not having suicidal ideation. March 2007 and August 2007 GAF Scores assigned during routine treatment visits were 55. One undated Vet Center record indicates that his wife is his primary motive for seeking treatment. The Veteran had a heart attack in August 2007. GAF scores in August 2007 (two weeks after the heart attack), October 2007, and December 2007 were 55. In his October 2007 substantive appeal to the Board, the Veteran wrote that he believed the VA was failing to consider his recent suicide attempt and his poor hygiene in assigning the appropriate disability rating for his PTSD. He was readmitted to the VA hospital for additional cardiac care in May 2008. The assigned GAF remained 55 at appointments in July and October 2008. The Veteran and his wife presented sworn testimony during a videoconference hearing in September 2008. During the course of the hearing, the Veteran described his problems sleeping, and his avoidance. He stated that he stays in his computer room most of the day, where he keeps the blinds drawn over the windows and does not answer the phone. He stated that his wife has to force him to take a bath. His wife testified that the Veteran had changed during the past three or four years. She explained that he snaps very easily and that his nightmares had worsened to the point where they could not sleep in the same room anymore. She had tried to find a job where she could work when he was sleeping so that she could be with him when he was awake, since he did not trust anyone else to be with him. She testified that she has to remind him to take a shower and change his clothes. A January 2009 VA treatment note reflects that the Veteran had been back in the hospital for three weeks, with complications involving his cardiac stent. It was thought that he may have suffered a stroke as well, based upon acute symptoms of memory loss and confusions. He continued manifesting depression and anger. He stated he imagined jumping out of a moving car when agitated, but his wife and thoughts of his grandkids grounded him. GAF scores in January 2009, February 2009, and March 2009 were again 55. The report of a May 2009 VA examination reflects the Veteran complained of recent anger. He stated he tried to jump out of a moving car, smashed a brand new television, tries to start fights with his neighbors, and sometimes picks at himself until he starts bleeding. Upon clinical examination, the examiner noted thought content including suicidal ideation, homicidal ideation, obsessions, ruminations, and paranoid ideation. He reported ongoing conflicts with his spouse. The examiner noted that the Veteran was having persistent paranoid delusions, and that he did not understand the outcome of his behavior. The examiner assigned a GAF Score of "45 to 50" and noted severe interpersonal, social, occupational, marital and family functioning impairment, and severe mental health symptoms, such as reexperiencing, avoidant and hyperarousal symptoms, severe sleep disturbance with nightmares, irritability, anger, violent behavior, homicidal ideation, panic attacks, severe avoidance behaviors, paranoid ideation, hypervigilence, constant thoughts of suicide, depressed mood, social withdrawal and isolation, problems with memory and concentration, poor hygiene, obsessive compulsive behaviors, anhedonia, and reported visual hallucinations. The examiner opined that the Veteran had total occupational and social impairment due to PTSD. It was noted that he had not worked since 2003-2004. He had ongoing conflicts with his spouse and generally had extreme difficulties related to interpersonal and social relationships. The veteran's prognosis was very guarded due to the chronicity and severity of his symptoms and impairments. In an undated statement, the Veteran's wife wrote of the Veteran's confusion, fear of crowds, fear of socializing in public, and his nightmares and demons. Applying the law to the facts of the case, as summarized above, the Board finds that the currently-assigned 70 percent disability rating more nearly approximates the Veteran's level of impairment due to PTSD with major depressive disorder from February 2003 until May 2009. As of the May 2009 VA examination report, however, the evidence reflects impairment more nearly approximating that described for a 100 percent schedular disability rating. The report of the May 2009 VA examination reflects greater impairment than any of the previous medical evidence of record. Not only was the GAF Score assigned by the examiner significantly lower (45 versus 55), but the examiner describes severe symptoms including hallucinations, paranoid ideation, homicidal ideation; none of which had previously been identified as present symptoms, let alone chronic symptoms. In reaching this conclusion, we observe that the Veteran has experienced some severe recent physical problems beginning in 2007, including recurrent heart problems, and a likely stroke. However, his medical care providers, including the therapist at the Vet Center and the psychiatric nurse practitioner who provides most of his care at the VA Medical Center, to include managing his prescription medications, did not view these problems as directly impacting the Veteran's mental health. Furthermore, the May 2009 VA examiner did not attribute any portion of the Veteran's decreased impairment to his physical problems. We note as well, that with the exception of the March 2006 examiner, no medical professional has attempted to separately identify symptomatology related to the Veteran's nonservice-connected personality disorder. Thus, in our discussion, the Board will attribute the Veteran's mental health symptomatology to his service-connected disability, unless otherwise clearly identified. The assignment of GAF scores under 60 represents the assessments of mental health professionals that the veteran has "moderate symptoms or moderate difficulty in social, occupational, or school functioning." With the exception of the lower GAF scores assigned during a brief period when the Veteran was hospitalized following his 2004 suicide attempt, the Veteran was consistently assigned GAF scores of 55 or higher throughout the appeal period prior to the May 2009 VA examination. The GAF score of 45 to 50, assigned by the May 2009 examiner, however, reflects "serious symptoms or any serious impairment in social, occupational, or school functioning,." DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, Fourth Edition, The American Psychiatric Association (1994), (DSM-IV). Overall, we find that the evidence of record supports a disability rating of no higher than 70 percent prior to the May 2009 VA examination. At no point prior to the May 2009 examination is total occupational and social impairment demonstrated for the record. As noted above, persistent delusions or hallucinations were not reflected in the evidence prior to May 2009. In our analysis, the Veteran's symptomatology does not rise to the level of the symptoms provided as examples of total occupational and social impairment in the General Rating Formula, prior to May 2009. Mauerhan. As of the May 2009 examination, however, the Veteran's symptoms appear to have worsened to the point where his symptomatology could be viewed as analogous to that described in the General Rating Formula. We place particular significance upon the examiner's assessment of the Veteran's rather bleak prognosis in conjunction with the reduced GAF score. As the Veteran had been receiving (and hopefully continues to seek) regular mental health care, including therapy and pharmacologic intervention, the "very guarded" prognosis is indicative of a more permanent decline in his level of functioning. In reaching this conclusion, the Board wishes to emphasize that we are in no way "giving up" on this Veteran's eventual improvement by assigning a 100 percent disability rating as of May 2009. Rather, we applaud his efforts to maintain balance in his life, given his severe mental health issues, combined with physical disease, and we encourage him to continue in his efforts to achieve greater wellness with the assistance of his wife, family, and his VA medical care providers; whose concern for him is apparent in their progress reports. However, it is the responsibility of the Board to ensure that the most appropriate disability rating is assigned to reflect a Veteran's individual level of functioning at any particular given point in time. Therefore, we hold that while the preponderance of the evidence is against the assignment of a disability rating in excess of 70 percent between February 2003 and May 2009, a 100 percent disability rating is warranted from May 2009 to the present. The appeal is thus granted to this extent. Extra-schedular consideration Generally, evaluating a disability using either the corresponding or analogous Diagnostic Codes contained in the rating schedule is sufficient. See 38 C.F.R. § 4.20, 4.27. For exceptional cases, VA has authorized the assignment of extraschedular ratings and provided the following guidance for awarding such ratings: To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, [C & P], upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b). As the Court recently explained in Thun, a "determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry." Thun v. Peake, 22 Vet. App. 111, 115 (2008). If the RO or Board determines that (1) the schedular evaluation does not contemplate the claimant's level of disability and symptomatology, and (2) the disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization, then (3) the case must be referred to an authorized official to determine whether, to accord justice, an extraschedular rating is warranted. Neither the RO nor the Board is permitted to assign an extraschedular rating in the first instance; rather the matter must initially be referred to those officials who possess the delegated authority to assign such a rating. See Floyd v. Brown, 9 Vet. App. 88, 95 (1996). Anderson v. Shinseki, 22 Vet. App. 423 (2009). In the current case, the Board finds that the schedular criteria are adequate to evaluate the Veteran's level of disability and symptomatology with respect to PTSD and major depressive disorder. No referral to the Under Secretary for Benefits or the Director of VA's Compensation and Pension Service would thus appear to be warranted. With regard to the Veteran's contention that his service-connected disabilities cause unemployability; this claim is not yet ripe for review, as his claim for a total disability rating based upon unemployability due to service- connected disability, assumed to include every possible theory of entitlement, is addressed in the REMAND portion of the decision below. ORDER An initial disability rating in excess of 70 percent for PTSD with major depressive disorder is denied from February 2003 until May 2009. A 100 percent disability rating for PTSD with major depressive disorder is granted from May 2009, subject to the laws and regulations governing the award of monetary benefits. REMAND The Veteran's representative contends that if the Board is unable to assign a 100 percent schedular disability rating, then a total disability rating based upon unemployability should be awarded. In this case, the question of whether the Veteran was rendered unemployable due to PTSD with major depressive disorder between February 2003 and May 2009 remains following the grant reached above. As a claim for a total disability rating based upon unemployability due to service-connected disability is part of an increased rating claim when such a claim is raised by the record (Rice v. Shinseki, 22 Vet. App. 447 (2009)), the analysis above applies to the question of whether the Veteran is rendered unemployable by his service-connected PTSD with major depressive disorder. Especially in this case, when the Veteran's only service- connected disability is PTSD with major depressive disorder, to the total functional impact of these disabilities upon the Veteran's employability must be viewed as part and parcel of the increased rating claim. Because he also has concurrently severe nonservice-connected physical disabilities, professional evaluation as to the effect of his PTSD with major depressive disorder upon his employability prior to May 2009 is needed. Although the veteran's claims file currently contains records reflecting his VA mental health treatment for the pertinent time period, we observe that complete records reflecting his care for his physical disabilities are not available for review. Any VA medical records are deemed to be constructively of record in proceedings before the Board and should be obtained prior to further review of the claims file. Bell v. Derwinski, 2 Vet. App. 611 (1992). Therefore to facilitate an informed opinion as to the Veteran's employability during the time period at issue, his complete VA medical records reflecting the time period between February 2003 and May 2009 should be obtained for inclusion in the claims file. Accordingly, the case is REMANDED for the following action: 1. The Veteran's complete VA medical records, reflecting care for all disabilities at the Iowa City VA Medical Center, and any other VA facilities, between February 2003 and May 2009, should be obtained for inclusion in his claims file. 2. The Veteran's claims file should be provided to a VA medical professional with relevant expertise in the areas of occupational medicine, employability, and mental health, for review of the medical evidence pertaining to his mental and physical impairment during the time period between February 2003 and May 2009, and an opinion as to his employability during that time period. The reviewer is requested to present an informed opinion as to whether the Veteran was rendered unemployable solely by his PTSD with major depressive disorder between February 2003 and May 2009. In reaching an informed conclusion, the reviewer is requested to specifically exclude all symptomatology related to the Veteran's nonservice-connected personality disorder and all physical impairment. The opinion should be expressed in terms of whether the Veteran's unemployed status was "more, less, or equally likely" due solely to his service-connected psychiatric disabilities. A complete explanation as to the conclusion reached should be included. 3. After the development requested above has been completed to the extent possible, the RO should again review the record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The Veteran has the right to submit additional evidence and argument on the matter 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 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. 2010). ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs