Citation Nr: 1300218 Decision Date: 01/03/13 Archive Date: 01/11/13 DOCKET NO. 11-06 415 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. What evaluation is warranted for posttraumatic stress disorder (PTSD) since October 16, 2008. 2. Entitlement to an increased evaluation for a duodenal ulcer, currently rated as 10 percent disabling. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities. 4. Entitlement to special monthly compensation based upon the need for aid and attendance and/or housebound status. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD H. Seesel, Counsel INTRODUCTION The Veteran had active service from July 1943 until February 1946. This matter came before the Board of Veterans' Appeals (Board) on appeal from January and December 2009 rating decisions from the Department of Veterans Affairs (VA), Regional Office (RO), in Cleveland, Ohio. The claim was certified by the RO in Pittsburgh, Pennsylvania. The Board remanded this appeal in September 2011. The RO/Appeals Management Center (AMC) completed all requested development on the claim being decided below, and the case has now been returned to the Board for further consideration. The issues of entitlement to an increased evaluation for a duodenal ulcer, entitlement to a total disability evaluation based on individual unemployability due to service connected disorders, and entitlement special monthly compensation based upon the need for aid and attendance and/or housebound status 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. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT Since October 16, 2008, the Veteran's PTSD has been manifested by occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW Since October 16, 2008, the criteria for a 50 percent evaluation for PTSD have been approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.125-4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). The Board finds the requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. In this case, the VCAA duty to notify was satisfied by way of the September 2009 letter. The claim was readjudicated in a March 2011 supplemental statement of the case. Concerning the duty to assist, the RO has obtained the service treatment, VA outpatient treatment records and reports of VA examinations. The Veteran submitted lay statements in support of his claim. The Veteran was afforded VA examinations in November 2008, September 2009, and October 2011. All of the VA examinations were thorough, each examination report included detailed findings that could be applied to the Schedule for Rating Disabilities, and the opinions provided were responsive to the questions posed. Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). Accordingly, the Board finds the VA examinations are adequate. There is no indication that there are additional records that have yet to be requested or that additional examinations are in order. As such the duty to assist has been fulfilled. The Merits of the Claim The Veteran claims entitlement to an increased evaluation for PTSD. The RO granted service connection for PTSD in a January 2009 rating decision, and assigned a 30 percent evaluation. The Veteran contends the current rating evaluation does not accurately reflect the severity of his disability and this appeal follows. 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. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify various disabilities and the criteria for specific ratings. If two disability 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. § 4.1. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. While the Veteran's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). When the Veteran is appealing the initial assignment of a disability rating, the severity of the disability is to be considered during the entire period from the initial assignment of the evaluation to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. PTSD is evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411. Regulations pertaining to the criteria for evaluating psychiatric disorders, including PTSD, provide for a 30 percent disability rating when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A higher 70 percent evaluation will be assigned where there is 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 work-like setting); and the inability to establish and maintain effective relationships. Id. In evaluating psychiatric disabilities, VA has adopted the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM -IV). That manual includes a Global Assessment of Functioning scale reflecting psychological, social and occupational functioning on a hypothetical continuum of mental illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV). A score of 41-50 indicates serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g. no friends, unable to keep a job). A score of 51-60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peer or coworkers). A score of 61 to 70 indicates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning, but generally functioning pretty well with some meaningful interpersonal relationships. The specified factors for each incremental psychiatric rating are not requirements for a particular rating but are examples providing guidance as to the type and degree of severity, or their effects on social and work situations. Thus, any analysis should not be limited solely to whether the symptoms listed in the rating scheme are exhibited; rather, consideration must be given to factors outside the specific rating criteria in determining the level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). That is, it is not the symptoms but their effects that determine the level of impairment. Id. The Veteran's claim for a higher evaluation stems from the initial grant of service connection in a January 2009 rating decision which granted entitlement to service connection for PTSD and assigned a 30 percent evaluation effective October 16, 2008. The Veteran has not appealed the effective date and therefore the Board considers findings from October 16, 2008. 38 C.F.R. § 3.400. The Veteran was afforded three VA examinations over the course of the appeal and had significant psychiatric treatment at VA facilities. During a November 2008 VA examination the Veteran reported symptoms of anxiety, hyperarousal, nightmares, intrusive thoughts, disrupted sleep, panic attacks, and some cognitive difficulty with memory. He also reported olfactory re-experiencing of symptoms particularly when exposed to gunpowder, fresh earth or blood. He described engaging in isolative behavior, but also reported being married to his second wife for over 20 years and having an outside friendship. Psychological testing revealed mild depression, and moderate difficulty with intrusive and avoidance symptoms typically associated with PTSD. The Veteran fell above the cut off for a diagnosis of PTSD in World War II veterans. The examiner concluded the symptoms were re-experiencing, avoidance and arousal with varying degree over the years but increased over the past two to three years. The examiner opined that the symptoms were moderate in intensity and occurred daily without treatment. The examiner opined the Veteran's PTSD symptoms would impact the productivity and efficiency of any employment but would not render him totally unemployable. During the September 2009 VA examination the Veteran reported symptoms of olfactory re-experiencing, nightmares, sleep disturbance, hypervigilance and hyperarousal. The Veteran described increased nightmares and intrusive thoughts but felt the hypervigilance, arousal, panic and other anxiety symptoms were slightly improved due to medication. He explained that he avoided psychotherapy as he did not want to talk or think about his wartime experiences and also avoided membership to military related organizations. There were no periods of remission and no inappropriate or reckless behavior. He reported being estranged from his four children but still lived with his second wife of 25 years. The examiner noted that the appellant's judgment and insight were fair to good. The Veteran denied both suicidal and homicidal ideation. No inappropriate behaviors were observed. He showed no impairment of speech, and he was pleasant and cooperative. The examiner concluded the Veteran continued to experience symptoms consistent with moderate PTSD which remained unchanged in overall severity. The Veteran was able to work one day per week from home suggesting his capacity for adjustment to fluctuations in symptom severity and frequency remained intact, and he was continuing to function well and was largely independently. Taken together, the examiner noted the amelioration of some symptoms and exacerbation of others which suggested that the overall severity of the PTSD was unchanged and was moderate in intensity. Symptoms impacted productivity and efficiency of any employment but would not render the Veteran totally unemployable. During the October 2011 VA examination the Veteran reported anxiety, arousal, avoidance, nightmares, sleep disruption, intrusive thoughts, olfactory re-experiencing and depression. The Veteran described some decreased interest in and pleasure from activities he used to enjoy, such as antique cars. He continued to enjoy art and art restoration. He described feelings of worthlessness and hopelessness, irritability and some visual hallucinations as he felt his house was haunted. He indicated he was not close to his children. He was married and described socializing with one other couple who also enjoyed art. The examiner indicated that although the Veteran was fully retired from art restoration due to lack of business, it did not appear that the symptoms of PTSD significantly affected the quality or quantity of his work. While there was an amelioration of some symptoms and exacerbation of others between the two prior VA examinations, the severity of the disorder was largely unchanged. The examiner indicated the symptoms were moderate in intensity and occurred daily without medication. While the Veteran reported increased irritability and arousal, the examiner opined that despite lack of treatment the appellant's symptoms had not worsened to the point of requiring psychiatric admission. The examiner opined that the appellant's symptoms did not cause suicidal thoughts or behaviors. There was no evidence of auditory or visual hallucinations. The examiner concluded that the Veteran was fully employable from a PTSD standpoint as he could tolerate schedule requirements, stress and interpersonal interactions required to maintain gainful employment. The examiner noted that the Veteran found work enjoyable and rewarding, and opined that the appellant was not working due to his advanced age and not an inability to work. On all three examinations the Veteran indicated he could perform self-care activities and generally functioned independently. He always denied suicidal ideation. The appellant avoided talking about military experiences and military organizations. Mental status examinations on all three dates reflected he was appropriately dressed and groomed. He was always oriented in all spheres but had some difficulty recalling specific dates in the past. Speech was always described as articulate and thoughts were logical and coherent. His judgment and insight were described as fair, although two examiners noted the Veteran's possession of a loaded gun could indicate recklessness. There was no evidence of delusion. The global assessment of functioning score at each of the three examinations was 55. VA outpatient treatment records since 2008 reflect the Veteran continually reported nightmares, poor sleep, intrusive thoughts, olfactory re-experiencing, depression and panic attacks. He also had significant avoidance of things that would make him talk or think about his service. Throughout the course of the appeal, the Veteran consistently reported having a good relationship with his wife, although he indicated he had few friends and generally described himself as isolated. He always denied suicidal thoughts or plan and denied hallucinations or delusions. The Veteran never showed evidence of impaired thought, and his speech was described as coherent and relevant. The assessment was almost always moderate posttraumatic stress disorder, although recent records in June and July 2012 described the condition as severe. The global assessment of functioning scores did decrease over the years from 55 assessed between 2008 and 2010, to 50 in June and July 2012. Evaluating the evidence in light of the pertinent rating criteria demonstrates that a 50 percent evaluation is approximated under the doctrine of reasonable doubt. The Veteran's symptoms from his PTSD included sleep impairment, frequent nightmares, panic attacks, hypervigilance, hyperarousal, olfactory re-experiencing, intrusive thoughts and depression. The Veteran was noted to experience symptoms daily. Although the intensity of the individual symptoms varied, the Veteran's PTSD has almost always been described as moderate in nature. The Veteran has always been oriented in all spheres, and demonstrated logical and coherent speech. He continued to enjoy working in art restoration and could function independently. The November 2008 and October 2011 VA examiners indicated that the symptoms of PTSD did not significantly affect the quality or quantity of work. Additionally, the global assessment of functioning score was generally 55, reflecting moderate symptoms. While the global assessment of functioning score has recently decreased to 50, denoting some serious symptoms, the Veteran's symptoms do not reflect such a severity. In fact, the June and July 2012 VA records that note this global assessment of functioning score report symptoms very similar to the symptoms noted in 2010 when the global assessment of functioning score was consistently rated as 55. Considering the global assessment of functioning scores in light of the symptoms noted to exist at the time of the score was assigned reflects the overall symptoms experienced by the Veteran are best contemplated by the criteria for the 50 percent rating. An evaluation in excess of 50 percent is not warranted at any time during the course of the appeal. The Veteran's symptoms have not been so frequent and disabling as to result in occupational and social impairment with deficiencies in most areas. Mauerhan. Although records in June and July 2012 suggest an increased in anxiety and nightmares, he was still oriented and had organized thought process and could carry on relevant and coherent conversation. While there is some social impairment noted by his isolation and relationship mainly with his wife and brother, his PTSD was noted to not have a significant effect on his employment. As noted above, the examiners noted the PTSD symptoms would have an impact on work but would not significantly affect the quality or quantity of work or render the Veteran unemployable. The Veteran consistently denied suicidal ideation, and he was always able to perform activities of daily living indicating he could function independently. While there was some impairment in judgment, specifically illustrated by his keeping a loaded gun for protection, his thinking was always coherent and logical. He never had impaired impulse control or neglected personal appearance or hygiene. In sum, the overall picture of the Veteran's PTSD is one of a moderate disability. As such, the record does not more nearly approximate a 70 percent evaluation at this time. Therefore, resolving reasonable doubt in the Veteran favor, a 50 percent rating, but no higher, for PTSD is granted. 38 U.S.C.A. § 5107(b). Extraschedular Rating The Board has also considered whether the Veteran's PTSD warrants referral for extra-schedular consideration. In exceptional cases where schedular disability ratings are found to be inadequate, consideration of an extra-schedular disability rating is made. 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extra-schedular disability rating is appropriate. See Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination concerning whether, to accord justice, the claimant's disability picture requires the assignment of an extra- schedular rating. Id. In this case, the evidence preponderates against finding that the Veteran's disability presents an exceptional disability picture, insofar as his symptoms are expressly contemplated by the rating schedule. As outlined above, the Veteran has reported nightmares, intrusive thoughts, avoidant behaviors, social isolation, anxiety, depression, sleep disturbance, irritability, hypervigilance and hyperarousal. Such symptoms are contemplated by the schedular criteria set forth in 38 C.F.R. § 4.130, Diagnostic Code 9411. The regulations expressly consider each of these symptoms and further allow for other signs and symptoms of PTSD and depression which may result in occupational and social impairment. In other words, the currently assigned Diagnostic Code 9411 adequately contemplates all of the Veteran's symptoms. As the rating criteria adequately contemplate the Veteran's symptoms, the first step of Thun has not been met and referral for the assignment of an extraschedular disability rating is not warranted. ORDER Entitlement to a 50 percent evaluation for posttraumatic stress disorder is granted subject to the laws and regulations governing the award of monetary benefits. REMAND With respect to the remaining issues the record reflects that additional development is necessary. The Veteran is entitled to substantial compliance with the Board's September 2011 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Unfortunately, the AMC did not fully comply with all of the Board's remand instructions and, as a result, this case must again be remanded. The September 2011 Board remand noted that the Veteran reported severe weight loss and bouts of anemia requiring a nutritional supplement. VA outpatient treatment records document fluctuating weight and continually note weight loss, anemia and malnutrition in the Veteran's past medical history. While some VA outpatient treatment records assert the Veteran's weight stabilized in 2007, other records, such as those dated in July 2010, report that he has lost more weight and even indicated that the appellant had an undesired weight status as evidenced by a body-mass index of 17. In the remand the Board directed that the examiner comment on the absence or presence of standard ulcer therapy, vomiting, hematemesis, melena, manifestations of anemia and weight loss. The November 2011 VA examiner simply stated there was no weight loss or anemia. Unfortunately, he did not comment upon the long history of weight loss and anemia noted throughout the record. The Board notes that some of the VA outpatient treatment records, such as records in 2007 and 2008, indicate that the Veteran's hiatal hernia could account for early satiety, but no rationale for this opinion was provided. As such, an addendum opinion must be provided to discuss whether the weight loss and anemia noted in the record are a result of the service-connected duodenal ulcer. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so). The September 2011 remand specifically directed the RO/AMC obtain a VA examination to address the claim for special monthly compensation based upon aid and attendance and/or housebound status. The Board requested opinions addressing whether the "service-connected disabilities alone" result in incapacity which would require the aid and attendance of another person. Following a November 2011 aid and attendance examination the examiner concluded that due to the Veteran's frail nature and overall health, he required daily personal healthcare services of the skilled provider without which he would require hospital nursing home or other institutional care. The examiner continued to opine that based on the "service connected conditions alone, for purposes of this exam which include the duodenal ulcer, the duodenal ulcer on its own would not preclude him unable to care of himself or to be employable." (Emphasis added). A review of the record, however, reflects the Veteran is also service-connected for posttraumatic stress disorder, hearing loss and tinnitus. As the examiner only considered the duodenal ulcer in determining whether the Veteran required the aid and attendance of another person, another VA examination is required. The law also provides that when a determination on one issue could have a significant impact on the outcome of another issue, such issues are considered inextricably intertwined and VA is required to decide those issues together. Harris v. Derwinski, 1 Vet. App. 180 (1991). In the present case, as the Veteran has a claim for an increased evaluation for a duodenal ulcer pending. Thus, adjudication of the claim for a total disability evaluation based on individual unemployability due to service connected disorders will be held in abeyance pending further development and adjudication of the Veteran's claim for his duodenal ulcer. Finally, the record reflects the Veteran has been treated at VA facilities. Updated VA treatment records should be obtained and associated with the record. Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. The RO/AMC should ask the Veteran to identify all sources of treatment that he has received for his service connected posttraumatic stress disorder, duodenal ulcer, hearing loss and tinnitus since October 2011, and provide any releases necessary for VA to secure records of such treatment or evaluation. The RO/AMC should obtain for the record copies of the complete records of all such treatment and evaluation from all identified sources. Updated treatment records from the VA Health Care Systems from August 2012 until the present should be requested and associated with the claims file. If the RO cannot locate such records, the RO must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The RO must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claims. The claimant must then be given an opportunity to respond. 2. After any requested records have been obtained, the RO/AMC must provide the November 2011 VA examiner the claims folder, a copy of this remand, and access to Virtual VA; and request clarification of the opinion regarding the severity of the duodenal ulcer with gastroneurosis. If the November 2011 VA examiner is unable to provide the requested opinion, the RO/AMC should request the opinion from another qualified physician. The examiner must comment on the absence or presence of the following: standard ulcer therapy, vomiting, hematemesis, melena, manifestations of anemia, and weight loss. The examiner must address any health impairment caused by the appellant's duodenal ulcer, to include the number of incapacitating episodes, if any, per year, and the duration of the episodes. The examiner must address the weight loss and anemia noted throughout VA outpatient treatment records. The examiner must opine whether it is at least as likely as not that weight loss and anemia are attributable to the service-connected duodenal ulcer, OR whether it is more likely than not that weight loss and anemia are due to a non-service-connected hiatal hernia or any other nonservice connected disorder. If the symptoms cannot be differentiated, the examiner should so state in the report. The claims file and Virtual VA must be reviewed in conjunction with this request and the report thereof should reflect that such review occurred. A thorough rationale, to include reference to relevant evidence of record as appropriate, should be provided for all opinions expressed. If the examiner is unable to provide a requested opinion, a supporting rationale must be given concerning why the opinion cannot be provided. 3. After any records requested above have been obtained, the RO/AMC should provide the November 2011 VA examiner the claims folder, as well as access to Virtual VA, and request clarification of the opinion regarding the Veteran's need for aid and attendance of another person and/or housebound status. If the November 2011 VA examiner is unable to provide the requested opinion, the RO/AMC should request the opinion from another qualified physician. The reviewer must provide a reasoned opinion on the specific questions listed below: (a) Does the combined impact of the Veteran's service-connected disabilities, i.e., PTSD, hearing loss, tinnitus, and duodenal ulcer with gastroneurosis, alone prevent him from protecting himself from the hazards incident to his environment, keeping himself clean and presentable, feeding himself due to loss of coordination of the upper extremities or extreme weakness, attending to the wants of nature, or render him bedridden, or otherwise require the regular aid and attendance by another person? (b) Do the service-connected disabilities (PTSD, hearing loss, tinnitus and duodenal ulcer with gastroneurosis) alone cause the Veteran to be unable to perform activities of daily living without the regular aid and attendance of another person or render him "permanently bedridden"? (c) Do the Veteran's service-connected disabilities (PTSD, hearing loss, tinnitus and duodenal ulcer with gastroneurosis) alone substantially confine him to his dwelling and the immediate premises, and is it reasonably certain that the disabilities and resultant confinement will continue throughout his lifetime? The claims file and Virtual VA must be reviewed in conjunction with this request and the examination report should reflect that review. A thorough rationale, to include reference to relevant evidence of record as appropriate, should be provided for all opinions expressed. If the examiner is unable to provide a requested opinion, a supporting rationale must be given concerning why the opinion cannot be provided. 4. The Veteran is to be notified that it is his responsibility to report for the examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for the aforementioned examination, documentation should be obtained which shows that notice scheduling the examination was sent to the last known address. It should also be indicated whether any notice that was sent was returned as undeliverable. 5. After the development requested has been completed, the RO/AMC must review the examination report to ensure that it is in complete compliance with the directives of this REMAND. The RO/AMC must ensure that the examiner documented his consideration of Virtual VA. If any report is deficient in any manner, the RO must implement corrective procedures at once. 6. Upon completion of the above development, and any additional development deemed appropriate, the RO/AMC must readjudicate the issues of entitlement to an increased evaluation for a duodenal ulcer, entitlement to a total disability evaluation based on individual unemployability due to service connected disorders, and entitlement to special monthly compensation based upon the need for aid and attendance and/or housebound status. If any benefit sought on appeal remains denied, the Veteran and his representative must be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs