Citation Nr: 1300102 Decision Date: 01/02/13 Archive Date: 01/11/13 DOCKET NO. 05-00 957 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for postoperative residuals of a gastric resection for peptic ulcer disease and an anastomotic ulcer. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for arthritis of multiple joints, to include as due to Agent Orange exposure. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD S. D. Regan, Counsel INTRODUCTION The Veteran had active service from November 1965 to October 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2004 RO rating decision that determined that new and material evidence had not been received to reopen a claim for entitlement to service connection for postoperative residuals of a gastric resection for peptic ulcer disease and an anastomotic ulcer (claimed as a bleeding ulcer). By this decision, the RO also denied service connection for tinnitus and for arthritis of multiple joints. In November 2007, the Board remanded the issue of whether new and material evidence has been received to reopen a claim for entitlement to service connection for postoperative residuals of a gastric resection for peptic ulcer disease and an anastomotic ulcer, as well as the issues of entitlement to service connection for tinnitus and for arthritis of multiple joints, to include as due to Agent Orange exposure, for further development. In April 2011, the Board reopened and remanded the issue of entitlement to service connection for postoperative residuals of a gastric resection for peptic ulcer disease and an anastomotic ulcer, and remanded the issues of entitlement to service connection for tinnitus and for arthritis of multiple joints, to include as due to Agent Orange exposure, for further development. The issues of entitlement to service connection for tinnitus and for arthritis of multiple joints, to include as due to Agent Orange exposure, 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. FINDING OF FACT The Veteran's post-operative residuals of a gastric resection for peptic ulcer disease and an anastomotic ulcer had its onset in service. CONCLUSION OF LAW Postoperative residuals of a gastric resection for peptic ulcer disease and an anastomotic ulcer were incurred in active service. 38 U.S.C.A. §§ 1110, 1112, 1113, 1154(a), 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board grants service connection for postoperative residuals of a gastric resection for peptic ulcer disease and an anastomotic ulcer. As this represents a complete grant of the benefits sought on appeal, no discussion of VA's duty to notify and assist is necessary. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection generally requires credible and competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet .App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection for a "chronic disease," such as peptic ulcers (gastric and duodenal), may be granted if manifest to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there must be a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, evidence of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2010). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. At 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Where service medical records are not available, the Board's obligation to explain its findings and conclusions and to consider the benefit-of-the-doubt rule is heightened. Pruitt v. Derwinski, 2 Vet. App. 83 (1992); O'Hare v. Derwinski, 1 Vet. App. 365 (1991). The Veteran contends that he has postoperative residuals of a gastric resection for peptic ulcer disease an anastomotic ulcer that are related to service. He specifically maintains that he was treated for stomach problems, including ulcers, during service and that he was hospitalized for bleeding ulcers after his discharge from service in 1970. He states that he subsequently underwent a gastric resection. The Veteran essentially indicates that he was treated for ulcer problems during service and he has suffered from ulcer problems since service. The Veteran's claims file has been rebuilt from available records. His available service treatment records do not show complaints, findings, or diagnoses of any ulcer or stomach problems. The Board notes, however, that private treatment records during the Veteran's period of service do show treatment for possible stomach problems. An April 1969 private treatment report from the Beaufort Memorial Hospital, during the Veteran's period of service, indicates that he was seen with a history and findings of abdominal pain and diarrhea of several days duration with no response to medications at home. It was noted that the Veteran also reported that he had marked nausea. Another April 1969 entry from the same facility, on the next day, notes that the Veteran continued to have abdominal pain, but that his diarrhea had been checked. Subsequent April 1969 entries from the Beaufort Memorial Hospital indicate that an upper gastrointestinal and small bowel serious, as well as a barium enema, were all normal. An April 1969 case summary relates a final diagnosis of gastroenteritis with diarrhea. A December 1970 hospital report from the Baroness Erlanger Hospital, approximately fourteen months after the Veteran's separation from service, reflects that he was admitted with a chief complaint of hematemesis. The Veteran reported that he had developed abdominal distress followed by the vomiting of some blood. He also stated that he had belching and epigastric burning. The examiner indicated that the Veteran had been a patient at that facility in August 1970 for rectal bleeding, an upset stomach with flatulence, and epigastric burning at bedtime over a two-week period. The examiner stated that, at that time, the Veteran was found to have a rectal polyp and he underwent a polypectomy and was found to have duodenitis. As to a physical examination, the examiner reported that the Veteran's abdomen currently showed moderate epigastric tenderness with mild generalized abdominal tenderness over the remainder of the abdomen. The impression was a probable bleeding ulcer. A December 1971 report from the Department of Surgical Pathology at Memorial Hospital, relates a diagnosis of portion of the stomach, about 50 to 50 percent, resection, for treatment of a chronic duodenal ulcer. (The actual operative report is not of record). Subsequent private and VA treatment records (including records contained within Virtual VA, a database containing a paperless version of the Veteran's claims file) show treatment for multiple disorders, including variously diagnosed stomach problems such as postoperative residuals of a gastric resection for pelvic ulcer disease and an anastomotic ulcer. For example, a January 1976 operative report from the Baroness Erlanger Hospital indicates that the Veteran underwent a gastroscopy with biopsy. The impression was marginal ulcers. An August 1978 VA treatment entry indicates that the Veteran was seen for complaints of a lot of pain in his stomach. It was noted that the Veteran had a history of surgery with 60 percent removal of his stomach. The diagnosis was duodenal ulcer, status postoperative. A February 1979 VA hospital summary reflects that the Veteran had a long history of peptic ulcer disease and that he had undergone a gastric resection and Billroth II anastomosis at the Memorial Hospital in 1971. The examiner reported that the Veteran did well for the next six or seven years with only occasional pain and no post-gastrectomy complications. It was noted that in August 1978, the Veteran began to have some social problems and he experienced epigastric pain that was only minimally relieved with large quantities of antacids. The examiner reported that an upper gastrointestinal series in October 1978 reveals edema at that anastomotic site. The examiner stated that an upper gastrointestinal series in December 1978 indicates that the Veteran had a marginal ulcer that was confirmed by endoscopy. It was noted that the Veteran was seen for further evaluation. The diagnoses were status post gastric resection for peptic ulcer disease with Billroth II anastomosis, and an anastomotic ulcer. A May 1979 VA hospital summary relates diagnoses of bile reflux gastritis and postoperative gastric reconstruction secondary to postoperative pancreatitis. A February 1985 VA treatment entry notes that the Veteran reported that he had undergone multiple surgeries for a stomach ulcer since 1979. He complained of a knot like feeling in his left abdomen, as well as nausea and difficulty keeping food down. A diagnosis was not specifically provided at that time. A February 2008 VA telephone note indicates that the Veteran reported that he had a lot of surgery on his stomach in 1970 and that he had suffered from dumping since that time. The Veteran stated that he had been losing control of his bowels over the past year. A diagnosis was not provided at that time. A March 2008 VA treatment entry notes that the Veteran reported that his diarrhea had improved, but that he still had diarrhea due to his previous surgery. The assessment included chronic diarrhea. An October 2008 VA treatment report indicates that the Veteran was seen for chronic diarrhea. It was noted that duodenal biopsies are normal and that random colon biopsies show increased eosinophils in lamina propria. The examiner reported that stool studies were negative. The assessment was gastroesophageal reflux disease and chronic diarrhea improved with Asacol. An August 2011 VA stomach, duodenum, and peritoneal adhesions examination report reflects that the Veteran's claims file was reviewed. The examiner reported that the Veteran was status post a gastric resection and that he had undergone three surgeries since 1970. The examiner stated that the Veteran underwent a gastric resection with Billroth II anastomosis for peptic ulcer disease in 1971 and that he underwent a vagotomy in 1979. It was noted that the Veteran had current post-prandial symptoms of diarrhea, nausea, and vomiting that would occur one to two hours after eating. The examiner indicated that such symptoms occurred daily or more often. The diagnosis was chronic colitis, status post gastrectomy and vagotomy for pelvic ulcer disease. The examiner indicated that the problem associated with the diagnosis was peptic ulcer disease. The examiner commented that it was as likely as not that the Veteran's gastric resection for peptic ulcer disease and an anastomotic ulcer had its onset during service. The examiner indicated that the Veteran had a gastric resection with Billroth II anastomosis in service in 1971. The examiner stated that the Veteran had been having abdominal pains since 1979 and that he underwent a vagotomy in 1979. The Board observes that the Veteran's available service treatment records do not specifically show treatment for ulcer or stomach problems. The Board notes, however, that the Veteran received private treatment during his period of service at the Beaufort Memorial Hospital in April 1969 for abdominal pain and diarrhea. An April 1969 case summary from that facility relates a diagnosis of gastroenteritis with diarrhea. The Board observes that a December 1970 hospital report from the Baroness Erlanger Hospital, approximately fourteen months after the Veteran's separation from service, specifically relates an impression of bleeding ulcers. Additionally, the examiner reported, at that time, that the Veteran had been treated in August 1970, within one year of his separation from service, for a rectal polyp and that he was found to have duodenitis. A subsequent December 1971 report from the Department of Surgical Pathology at Memorial Hospital, relates a diagnosis of portion of the stomach, about 50 to 50 percent, resection, for treatment of a chronic duodenal ulcer. Unfortunately, the actual operative report is not of record. The Board observes that a February 1979 VA hospital summary indicates that the Veteran underwent a gastric resection and Billroth II anastomosis at the Memorial Hospital in 1971. The diagnoses, at that time, were status post gastric resection for peptic ulcer disease with Billroth II anastomosis, and an anastomotic ulcer. The Veteran continued to receive treatment for variously diagnosed ulcer and stomach complaints. The Board observes that an August 2011 VA stomach, duodenum, and peritoneal adhesions examination report relates a diagnosis of chronic colitis, status post gastrectomy and vagotomy for pelvic ulcer disease. The examiner commented, after a review of the Veteran's claims file, that it was as likely as not that the Veteran's gastric resection for peptic ulcer disease and an anastomotic ulcer had its onset during service. The examiner indicated that the Veteran had a gastric resection with Billroth II anastomosis in service in 1971. The examiner stated that the Veteran had been having abdominal pains since 1979 and that he underwent a vagotomy in 1979. The Board observes that the VA examiner incorrectly reported that the Veteran underwent the gastric resection with Billroth II anastomosis during his period of service. The Veteran underwent such surgery in December 1971 and he was discharged from service in October 1969. The Board observes, however, that the Veteran was diagnosed with duodenitis in August 1970 within one year of his separation from service, and with bleeding ulcers in December 1970, within approximately fourteen months of his separation from service. Additionally, although the VA examiner was incorrect on the 1971 date, she specifically concluded that it was as likely as not that the Veteran's gastric resection for peptic ulcer disease and an anastomotic ulcer had its onset during service. The Board also notes that there are no negative etiological opinions of record. Further, the Board observes that the Veteran is competent to report that he had stomach problems in service and stomach problems since service. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Moreover, the Board finds that his account is credible. See Jandreau v. Nicholson, 492 F.3d 1372 (2007) (holding that lay evidence can be competent and sufficient to establish a diagnosis of a condition when a lay person is competent to identify the medical condition, or reporting a contemporaneous medical diagnosis, or the lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). After considering all the evidence, to specifically include the opinion from the VA examiner pursuant to the August 2011 VA stomach, duodenum, and peritoneal adhesions examination, the Board finds that that the Veteran has current postoperative residuals of a gastric resection for peptic ulcer disease and an anastomotic ulcer that had their onset during service. Postoperative residuals of a gastric resection for peptic ulcer disease and an anastomotic ulcer were incurred in active service, warranting service connection. The benefit-of-the-doubt rule (38 U.S.C.A. § 5107(b)) has been considered in making this decision. ORDER Service connection for postoperative residuals of a gastric resection for peptic ulcer disease and an anastomotic ulcer is granted. REMAND The remaining issues on appeal are entitlement to service connection for tinnitus and entitlement to service connection for arthritis of multiple joints, to include as due to Agent Orange exposure. The Board finds that there is a further VA duty to assist the Veteran in developing evidence pertinent to his claims. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). This case was previously before the Board in April 2011, partly to schedule the Veteran for an appropriate VA examination to ascertain the etiology of his current tinnitus. The examiner was requested to express an opinion as to whether it was at least as likely as not that the Veteran's tinnitus was related to or had its onset in service. The examiner was specifically requested to acknowledge and discuss the Veteran's competent report regarding the onset of his tinnitus as well as his in-service noise exposure. Pursuant to the April 2011 remand, the Veteran was afforded a VA audiological examination in August 2011. The diagnoses included subjective tinnitus. The examiner stated that the etiology of the Veteran's tinnitus could not be determined on the basis of available information without resorting to speculation. The examiner indicated that she provided an opinion, pursuant to a January 2009 VA audiological examination report, that it was not likely that the Veteran's current hearing loss was related to his military service. The examiner stated that she was not inclined to change her opinion as there was no new evidence to the contrary. The examiner stated that the Veteran did not report tinnitus at a 2008 VA evaluation or at the January 2009 VA audiological examination, and that he reported that the onset of his tinnitus was a couple years ago. The examiner stated that there was no scientific evidence to support that delayed onset tinnitus could occur from noise exposure decades removed. The examiner reported that Noise and Military Service, Implications for Hearing loss from the Institute of Medicine indicates that as the interval between a noise exposure and the onset of tinnitus lengthens, the possibility that tinnitus will be triggered by other factors increases and that a more complete understanding of the mechanisms by which tinnitus was generated would be needed before the existence of the delayed onset noise-induced tinnitus could be confirmed or rejected. The examiner maintained that such medical treatise implied that the probability of tinnitus being related to noise exposure did decrease the greater the time of onset is removed from the time of the noise exposure. The examiner indicated that most audiologists had generally used the rule-of-thumb of a one to two year cutoff. The examiner reported that, therefore, if a Veteran reported the onset of tinnitus after such timeframe then it became less likely as not that the tinnitus was due to noise exposure in service. The examiner commented that it was her opinion that the Veteran's current tinnitus was less likely as not related to his military noise exposure. The Board observes that the VA examiner did not acknowledge and discuss the Veteran's report that he suffered from tinnitus during and since his period of service. For example, in a June 2005 statement, the Veteran specifically reported that he had ringing in the ears since service and that it had only worsened. Additionally, the Veteran is competent to report that he had ringing in the ears in service and ringing in the ears since service. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Additionally, the VA examiner's statement that the Veteran did not report tinnitus prior to a 2009 VA audiological examination is also not correct. Further, the Board notes that the examiner did not specifically address the fact that the Veteran is presently service-connected for bilateral hearing loss. In fact, she restated her opinion that the Veteran's bilateral hearing loss was not related to his period of service. As to the Veteran's claim for entitlement to service connection for arthritis of multiple joints, to include as due to Agent Orange exposure, the April 2011 Board remand indicated that the Veteran should be afforded an appropriate VA examination to ascertain the etiology of his currently diagnosed arthritis of multiple joints. The examiner was requested to express an opinion as to whether it was likely as not that the Veteran's arthritis of multiple joints was related to his active military service, to include his in-service Agent Orange exposure. Pursuant to the April 2011 Board remand, the Veteran was afforded a VA orthopedic examination in August 2011. The diagnoses were osteoarthritis of multiple joints and status post a right total knee replacement. The examiner indicated that her opinion was unchanged since a previous opinion provided pursuant to a January 2009 VA orthopedic examination report. The examiner commented that the Veteran's arthritis of multiple joints was less likely as not caused by or a result of his military service. The examiner provided rationales for her opinion that included a discussion of various degenerative changes to multiple joints, including the Veteran's knees. The Board notes, however, that the VA examiner did not address whether the Veteran's claimed arthritis of multiple joints was related to his in-service Agent Orange exposure as specifically requested pursuant to the April 2011 remand. A remand by the Board confers upon a Veteran, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). As the development requested pursuant to the April 2011 remand has not been accomplished, the Board finds that the Veteran must be afforded a VA examination with the opportunity to obtain responsive etiological opinions, following a thorough review of the entire claims folder, as to his claims for service connection for tinnitus and for arthritis of multiple joints, to include as due to Agent Orange exposure. Such examinations should be accomplished on remand. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Prior to the examinations, any outstanding records of pertinent medical treatment should be obtained and added to the record. Accordingly, the case is REMANDED for the following: 1. Ask the Veteran to identify all medical providers who have treated him for tinnitus and arthritis of multiple joints since April 2010. After receiving this information and any necessary releases, contact the named medical providers and obtain copies of the related medical records which are not already in the claims folder. Specifically, VA treatment records since April 2010 should be obtained. In the event the Veteran identifies treatment by a private provider, the RO must document that it has made at least two requests to the custodian of the private records to obtain the records unless it is made evident by the first request that a second request would be futile in obtaining such records. 2. Schedule the Veteran for an appropriate VA examination to determine the nature, etiology and/or onset of his tinnitus. The claims folder must be provided to and reviewed by the examiner. Based on a review of the claims file and examination of the Veteran, the examiner should provide a medical opinion, with adequate rationale, as to whether it is at least as likely as not that any currently diagnosed tinnitus was incurred in service, or is the result of exposure to acoustic trauma during the Veteran's period of service. The examiner must specifically acknowledge and discuss the Veteran's report that his tinnitus first manifested during his period service. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (holding that an examination was inadequate where the examiner did not comment on the Veteran's report of in-service injury and relied on the absence of evidence in the Veteran's service medical records to provide a negative opinion). The examiner should then opine as to whether the Veteran's service-connected bilateral hearing loss caused or aggravated any diagnosed tinnitus. All findings and conclusions must be set forth in a legible report. 3. Schedule the Veteran for appropriate VA examination to determine the nature, etiology and/or onset of his claimed arthritis of multiple joints, to include due to Agent Orange exposure. The claims folder must be provided to and reviewed by the examiner in conjunction with the examination. Based on a review claims file, examination of the Veteran, and generally accepted medical principles, the examiner should provide a medical opinion, with adequate rationale, as to whether it is at likely as not that the Veteran's arthritis of multiple joints is etiologically related to or had its onset in service. The examiner must specifically indicate whether the Veteran's arthritis of multiple joints is related, at least in part, to his presumed in-service Agent Orange exposure. In doing so, the examiner must identify all joints involved, and must specifically rule in or exclude a relationship between a knee condition and service. The examiner must specifically acknowledge and discuss any reports by the Veteran that his claimed arthritis of multiple joints was first manifested during his period service. See Dalton. All findings and conclusions must be set forth in a legible report. 4. Then readjudicate the appeal. If any benefit sought remains denied, issue a supplemental statement of the case to the Veteran and his representative, and provide an opportunity to respond before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs