Citation Nr: 1237010 Decision Date: 10/25/12 Archive Date: 11/08/12 DOCKET NO. 09-42 026A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for bilateral knee disability. 2. Entitlement to service connection for bilateral ankle disability. 3. Entitlement to service connection for bilateral shoulder disability. 4. Entitlement to service connection for bilateral hand disability. 5. Evaluation of bilateral hearing loss disability, currently rated as 50 percent disabling. 6. Evaluation of residuals of left forearm fracture, currently rated as 20 percent disabling. 7. Evaluation of surgical scars of the left forearm and wrist, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T.S. Willie, Counsel INTRODUCTION The Veteran served on active duty from February 1960 to February 1964. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Columbia, South Carolina Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Acting Veterans Law Judge (AVLJ) in June 2011. A transcript of the hearing has been associated with the record. Additional records were associated with the file since the March 2011 Supplemental Statement of the Case (SSOC). The Veteran, however, waived RO consideration of the evidence in the first instance during his June 2011 hearing. The issues of evaluation of bilateral hearing loss disability, currently rated as 50 percent disabling, and evaluation of residuals of left forearm fracture, currently rated as 20 percent disabling, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. A bilateral knee disability was not manifest in service and arthritis was not manifest within a year of separation. A bilateral knee disability is not otherwise attributable to service. 2. A bilateral ankle disability was not manifest in service and arthritis was not manifest within a year of separation. A bilateral ankle disability is not otherwise attributable to service. 3. A bilateral shoulder disability was not manifest in service and arthritis was not manifest within a year of separation. A bilateral shoulder disability is not otherwise attributable to service. 4. A bilateral hand disability was not manifest in service and arthritis was not manifest within a year of separation. A bilateral hand disability is not otherwise attributable to service. 5. Surgical scars of the left forearm and wrist are manifested by four painful scars. CONCLUSIONS OF LAW 1. A bilateral knee disability was not incurred in or aggravated by service, nor can arthritis be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002 and Supp. 2011); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. A bilateral ankle disability was not incurred in or aggravated by service, nor can arthritis be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002 and Supp. 2011); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 3. A bilateral shoulder disability was not incurred in or aggravated by service, nor can arthritis be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002 and Supp. 2011); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 4. A bilateral hand disability was not incurred in or aggravated by service, nor can arthritis be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002 and Supp. 2011); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 5. Surgical scars of the left forearm and wrist are 20 percent disabling. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2011); 38 C.F.R. § 4.118; Diagnostic Codes 7800-7805 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2011), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002), requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Prinicpi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial disability-rating and effective-date elements of a service connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The record reflects that the originating agency provided the Veteran with the notice required under VCAA by letters dated in December 2008 and October 2009. With regard to the claim an increased rating for surgical scars, the Board notes that the Veteran is challenging the disability evaluation assigned following the grant of service connection. In Dingess, the U.S. Court of Appeals for Veterans Claims held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, supra. at 490-191. Thus, VA's duty to notify in this case has been satisfied. Moreover, the Board notes that the Veteran was afforded a hearing before the undersigned Acting Veterans Law Judge in June 2011. At the start of the hearing, the AVLJ clarified the issues on appeal. During the hearing, there was discussion regarding additional evidence required to substantiate his claims. This action supplements VA's compliance with the VCAA and satisfies 38 C.F.R. § 3.103. VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). In connection with the current appeal, available service records have been obtained. With regard to the claim for an increased rating for surgical scars, the Board notes that the Veteran has been afforded an adequate examination for this claim as the examiner reviewed the history and established clinical findings. The Board acknowledges that the Veteran has not been afforded a VA examination in relation to his claims for service connection. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the Veteran's service treatment records reflect that his shoulders, hands, knees, and ankles were normal when he separated from service in 1964. The Veteran stated that he first sought treatment for arthritis in his knees and ankles in 1967 - three years after separation. The first documented evidence of arthritis of the lower extremities is contained in a July 2005 private treatment record. Later VA outpatient treatment records reference arthritis of multiple joints. To the extent the Veteran claims continuity of symptomatology, as discussed below, this is inconsistent with the record and the Board does not find such assertions credible. Furthermore, there is no evidence to suggest that any of the Veteran's claimed joint problems are attributable to service such as to require an examination, even under the low threshold of McLendon. As such, a VA examination is not warranted to address the issues for service connection. For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claims. The evidence of record provides sufficient information to adequately evaluate the claims, and the Board is not aware of the existence of any additional relevant evidence which has not been obtained. No further assistance to the Veteran with the development of evidence is required. 38 U.S.C.A. § 5103A(a)(2) ; 38 C.F.R. § 3.159(d). Accordingly, the Board will address the merits of the claims. SERVICE CONNECTION The Veteran has appealed the denial of service connection for disabilities of the knees, ankles, shoulders and hands. Service connection means that the facts establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Certain chronic diseases, such as arthritis, may be service connected if manifested to a degree of 10 percent disabling or more within one year after separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309 (2012). For a showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. If the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). The Board notes that the provisions of 38 U.S.C.A. § 1154(b) do not apply, as it has not been claimed that the disabilities were incurred while engaging in combat. The Veteran asserts that during service he did a lot of climbing and that his construction job in service required extensive physical activity. He asserts the physician nature of his work strained his shoulders, hands, knees, and ankles, which resulted in his current disabilities. He reported that as he separated from service the problems persisted and continues today. Service treatment records note that the Veteran sustained a puncture wound of the palm of left hand in July 1963, but are otherwise unremarkable for any complaints, treatment, or diagnoses related to the shoulders, hands, knees, and ankles. The January 1964 separation examination revealed normal findings for the upper and lower extremities. In an October 2009 statement, the Veteran said that he first went to a doctor for his knees and ankles in 1967. He said the doctor told him that he had arthritis and would have these problems for the rest of his life. He was told to take aspirin for the pain. In his January 2010 notice of disagreement, he said he sought treatment for arthritis in his arms, shoulders, and knees in the late 1960s and early 1970s, but he did not have any of the treatment records. During the Board hearing, he said he could not remember the names of the doctors he saw during this time period. The first documented evidence of arthritis is contained in a July 2005 private treatment record from Dr. Esposito. It was noted that the Veteran complained of aching in his lower extremity after a long day at work and it was noted that he had long-standing degenerative joint disease (DJD) (i.e., arthritis). In February 2006, it was noted that the Veteran had DJD of the lower extremities. In July 2006, it was noted that the Veteran injured his knees at work when he tripped and fell and the physician indicated there was probably exacerbation of his osteoarthritis and connective tissue trauma. VA outpatient treatment records dated from June to December 2010 note a history of osteoarthritis and degenerative joint disease of multiple joints, specifically noting the right hip, left hip, left knee, and right ankle. After review of the record, the Board finds that the more probative evidence is against a finding that the Veteran has disabilities of the knees, ankles, hands and/or shoulders that are related to service. In this regard, service treatment records are negative for any treatment, diagnoses and/or complaints for the knees, shoulders and/or ankles. To the extent that the Veteran was treated for a puncture wound of the left palm in July 1963, no other complaints were shown in the service treatment records and his separation examination was normal for the upper extremities. The Veteran's separation examination also revealed normal findings for the lower extremities and arthritis is not shown within a year of separation. The Board has considered the Veteran's statements and testimony. As a layperson, he is certainly competent to report on matters observed or within his or her personal knowledge, such as joint aches and pains, and the circumstances surrounding such to include climbing and other physical activities. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board finds his description of the work he performed during service and his reports of current joint problems are credible. To the extent he reports continuity of symptomatology; however, the Board does not find his statements credible. In this regard, the Board points out that the Veteran's service treatment records are unremarkable for a chronic knee, hand, shoulder and/or ankle disability or injury during service. In his earlier statements, he said that he first sought treatment and was diagnosed with arthritis of the knees and ankles in 1967 or in the late 1960s - several years after he separated from service. Furthermore, the first objective indication of any of the disabilities is in July 2005. The Board notes that the passage of decades between discharge from active service and the objective documentation of a claimed disability is evidence against continuity of symptomatology and a factor that weighs against a claim for service connection. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim); see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board's denial of service connection where veteran failed to account for lengthy time period between service and initial symptoms of disability). Here, the Board is not presented with silence alone but rather normal findings at separation and a gap in time. Here, the Board notes that it has carefully considered the Veteran's lay statements to the effect that his claimed disabilities are causally related to the work he performed in service over 40 years ago; however, the Board finds that such statements alone do not provide a basis upon which to grant the claims. Such an etiological opinion is a complex medical question beyond the ken of a layman and not susceptible to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The Board has weighed the Veteran's statements and finds his current recollections and statements made in connection with a claim for VA compensation benefits to be of less probative value than the normal findings during service and the gap in time between service and objective evidence of record. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). RATINGS Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.10 (2012). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service- connected disability exhibits symptoms that would warrant different ratings.); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). A disability may require re-evaluation in accordance with changes in a veteran's condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. We conclude that the disability has not significantly changed and that a uniform rating is warranted during the time frame addressed in this decision. The Veteran has appealed the assignment of a 10 percent rating for surgical scars of the left forearm and wrist. The criteria for rating scars were revised, effective October 23, 2008. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). As the Veteran's claim was filed in November 2008, the new criteria apply. Id. Under the revised Diagnostic Code 7805, other scars (including linear scars) and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, and 7804 require the evaluation of any disabling effect(s) not considered in a rating provided under diagnostic codes 7800-04 under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 (2012). To warrant a higher rating the evidence must show a deep and nonlinear scar that is at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.) (Diagnostic Code (DC) 7801). A higher rating may also be warranted for three or four scars that are unstable or painful (DC 7804). The April 2010 VA examination revealed that the Veteran had scarring following the operation to correct his left arm fractures in service. The scars were all vertical. He had a 3.5 cm scar on the left wrist, a 9.5 cm scar on the left forearm radial side and a 4.5 cm scar below the elbow posterior aspect of the forearm. All the scars were well healed and there were no changes in coloration or disfigurement from the scars. The Veteran reported some tingling but said it was not present all the time, although he was conscious of it every day. Examination revealed touching the larger scars elicited tingling, otherwise sensation was normal. There were no signs of major peripheral nerve damage. The operative scars on the left forearm were found to be more of a minor inconvenience than a major disability. During his June 2011 hearing, the Veteran reported having four scars to include scars on the elbow, front side of the forearm, back side of the forearm and the wrist. He expressed that the scars were tender to touch and tingly. He also reported discoloration from his normal skin. Based on the evidence presented, the Board finds that the evidence for a higher 20 percent for the surgical scars of the left forearm and wrist is at least in equipoise. In this regard, the Veteran has described a tender, tingling sensation in the scars of his left forearm. Furthermore, examination in April 2010 revealed touching the larger scars elicited a tingling sensation. The Board finds that the lay evidence reflects the symptoms required for a 20 percent rating, i.e. three or four scars that are painful. See 38 C.F.R. § 4.118, DC 7804 (2012). The Board, however, notes that the scars have not been deemed unstable during examination, and as such, an additional 10 percent is not warranted for unstable and painful scars. 38 C.F.R. § 4.118, DC 7804, note 2. Although the Board finds that the evidence supports the assignment of a rating of 20 percent disabling for surgical scars of the left forearm and wrist, the evidence is against a rating higher than 20 percent disabling. At most, the evidence shows scars up to 9.5 cm in length that are well healed. The scars are not of the severity or of size so as to warrant a rating higher than 20 percent disabling under the rating criteria pertaining to scars. See 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805 (2012). It is also noted that no more than four painful scars has been reported so as to warrant a higher rating under 38 C.F.R. § 4.118, Diagnostic Code 7804 (2012). The Veteran is competent to report that his disability is worse than evaluated, and we find his reports of symptomatology to be credible. However, neither the lay nor medical evidence reflects the criteria required for a rating higher than 20 percent disabling. Accordingly, a 20 percent, but no higher, rating for surgical scars of the left forearm and wrist is warranted. The Board further notes that referral for extraschedular consideration is not warranted. Consideration of referral for an extraschedular rating requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. Here, the Board finds that the record reflects that the Veteran has not required frequent periods of hospitalization for his disabilities and that the manifestations of the disabilities are contemplated by the schedular criteria. Therefore, there is no reason to believe that the average industrial impairment from the disabilities would be in excess of that contemplated by the schedular criteria. Therefore, referral of the case for extra- schedular consideration is not in order. The Board has also considered the Court's decision in Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). In this case, the record on appeal indicates that the Veteran reported that he last worked in August 2008 as a superintendent in a plumbing business. He said he experienced no limitation in his work from his left forearm (see March 2009 VA examination). In this case, the Veteran does not contend and the evidence does not otherwise show that he is unemployable as a result of his service-connected left forearm scars. Absent probative evidence of unemployability, consideration of a total rating based on individual unemployability due to service-connected disability is not warranted. In this case, the Board concludes that there is no basis for staged ratings of the Veteran's left forearm scars and that a higher 20 percent rating is warranted throughout the appeal period. In reaching this decision, the Board has favorably applied the benefit-of-the-doubt doctrine; however, the Board finds that the preponderance is against assignment of any higher rating. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER Service connection for a bilateral knee disability is denied. Service connection for a bilateral ankle disability is denied. Service connection for a bilateral shoulder disability is denied. Service connection for a bilateral hand disability is denied. A 20 percent rating for surgical scars of the left forearm and wrist is granted, subject to the controlling regulations applicable to the payment of monetary benefits. REMAND The Veteran has appealed the denial of a rating higher than 50 percent disabling for his bilateral hearing loss disability. In relation to his claim, the Veteran was afforded VA audiological examinations in June 2009 and November 2010. During his June 2011 hearing, however, he stated that his hearing loss had worsened. The Veteran has also appealed the denial of a rating higher than 20 percent for residuals of a left forearm fracture. The record shows that in his March 2009 VA examination the Veteran did not require a brace or supportive device. However, in his June 2011 hearing, he presented wearing a brace and said that he now wore a brace for his disability. He also described neuropathy symptoms in his left forearm. Pursuant to 38 U.S.C.A. § 5103A(d)(2) and 38 C.F.R. § 3.159(c)(4)(i), VA will obtain an examination or an opinion if it is necessary to decide the claim. Here, the Veteran has reported a worsening of his hearing loss since his last examination and his recent statements indicate a worsening of his residuals of left forearm fracture, as such another examination is warranted to properly adjudicate the claims. In view of VA's duty to assist obligations, which include the duty to obtain a VA examination or opinion when necessary to decide a claim, and based upon guidance from the Court, remand for the purpose of obtaining a VA examination(s) is required. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA audiology examination to determine the severity of his bilateral hearing loss disability. All appropriate tests and studies should be accomplished and all clinical findings should be reported in detail. 2. Schedule the Veteran for a VA examination to determine the severity of his residuals of left forearm fracture disability. All appropriate tests and studies should be accomplished and all clinical findings should be reported in detail. Range of motion testing should be conducted and the examiner must clearly state at which point pain begins. The examination report should also include findings consistent with the criteria of DeLuca v. Brown, 8 Vet. App. 202 (1995). The examiner should also indicate whether there are any neurological manifestations associated with the residuals of the left forearm fracture disability. If so, the examiner should identify all nerve(s) involved and degree of impairment to include all symptoms and manifestations (whether the involvement is only sensory, or if it is characterized by organic changes such as loss of reflexes, muscle atrophy, sensory disturbances, constant pain as well as a characterization of the symptoms as to whether they represent complete paralysis or incomplete paralysis). If incomplete paralysis is represented by the manifestations this should be characterized as mild, moderate or severe (with or without marked muscular atrophy). A complete rationale should be provided for any opinion(s) expressed. 3. If upon completion of the above action any benefit sought remains denied, the case should be returned to the Board after compliance with requisite appellate procedures. 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). These claims must be afforded expeditious treatment. The law requires that all claims 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. 2011). ______________________________________________ SONJA A. MISHALANIE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs