Citation Nr: 1300849 Decision Date: 01/09/13 Archive Date: 01/16/13 DOCKET NO. 05-29 209 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Providence, Rhode Island THE ISSUES 1. Entitlement to service connection for tinnitus. 2. Entitlement to a rating in excess of 20 percent for peripheral neuropathy of the left lower extremity. 3. Entitlement to a rating in excess of 20 percent for peripheral neuropathy of the right lower extremity. 4. Entitlement to a total disability rating based on individual unemployability (TDIU) for the period prior to July 20, 2010. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Barone, Counsel INTRODUCTION The appellant is a veteran who served on active duty from October 1968 to June 1971. These matters are before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Cleveland, Ohio, Department of Veterans Affairs (VA) Regional Office (RO). In December 2007, a Travel Board hearing was held before the undersigned; a transcript of that hearing is associated with the claims file. In February 2008 the Board remanded this case for further development. In August 2011, the Board again remanded this case for further development. The Board finds that there has been compliance with the directives of the Board's August 2011 remand with regard to the tinnitus issue decided herein. In this regard, a September 2011 letter sent to the Veteran provided all notice specifically appropriate for a claim of secondary service connection. The Veteran was previously represented by Virginia A. Girard-Brady, Attorney at law. A September 2011 signed statement withdrew that representation. A duly executed VA Form 21-22, submitted in May 2012, appoints Disabled American Veterans as the Veteran's new representative. The Board notes that this appeal includes issues that were previously addressed under two separate docket numbers(and by two Board decisions in August 2011). The August 2011 Board decisions resolved several issues and remanded those remaining on appeal for additional development. Of the issues remaining on appeal, the TDIU issue came from one docket number and each of the other issues came from the other (older) docket number. At this time, however, there appears to be no useful purpose served by maintaining both docket numbers or issuing separate Board decisions on these issues; all issues remaining on appeal arise from the same agency of original jurisdiction, feature the same representative, and involve substantially the same evidentiary record. The Board has therefore merged the TDIU issue into the docket number that already included the other issues on appeal. The Board notes that it is entirely appropriate to consider the TDIU issue together with the other issues on appeal; the TDIU issue is inextricably intertwined with the other issues, and the increased rating issues on appeal include contentions of unemployability which themselves raise the TDIU issue. The issues regarding the ratings for peripheral neuropathy of both lower extremities, and entitlement to a TDIU rating for the period prior to July 20, 2010 are being REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action on his part is required. FINDING OF FACT The Veteran's tinnitus was not manifested in service and is not shown to be related to his service, or to have been caused or aggravated by his service-connected diabetes mellitus. CONCLUSION OF LAW Service connection for tinnitus, claimed as secondary to service-connected diabetes mellitus, is not warranted. 38 U.S.C.A. §§ 1110, 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012), 3.310 (as in effect prior to Oct. 10, 2006). REASONS AND BASES FOR FINDING AND CONCLUSION A. Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claim. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was advised of VA's duties to notify and assist in the development of his claim prior to its initial adjudication. A May 2004 letter explained the evidence necessary to substantiate his claim, the evidence VA was responsible for providing, and the evidence he was responsible for providing. In accordance with the Board's August 2011 remand, an additional notice letter was sent to the Veteran in September 2011. This more recent notice letter again explained the evidence necessary to substantiate his claim, the evidence VA was responsible for providing, and the evidence he was responsible for providing; it furthermore informed him of disability rating and effective date criteria, and provided all notice specifically appropriate for a claim of secondary service connection. The Veteran has had ample opportunity to respond/supplement the record and he has not alleged that notice in this case was less than adequate. While adequate notice was arguably not provided prior to the initial adjudication of the instant claim, the case was subsequently readjudicated in a November 2011 supplemental statement of the case (SSOC), curing any notice timing defects. Prickett v. Nicholson, 20 Vet. App. 370 (2006). Copies of the Veteran's available pertinent service treatment records (STRs) are associated with his claims file. His pertinent available postservice treatment records have been secured. He was afforded a VA examination addressing the instant matter in June 2008. As discussed below, the Board finds that the report of that examination is adequate for the purpose of this decision. The Board finds there has been compliance with the instructions of the August 2011 remand regarding the tinnitus issue decided herein. The Veteran has not identified any pertinent evidence that remains outstanding. Accordingly, the Board finds that VA's duty to assist is met and will address the merits of the claim. B. Legal Criteria, Factual Background, and Analysis Initially, the Board notes all of the evidence in the Veteran's claims file and in Virtual VA (VA's electronic database storage), with an emphasis on the evidence relevant to this appeal, has been reviewed. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially 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). To substantiate a claim of service connection, there must be medical evidence of a current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). Service connection may be established on a secondary basis for a disability that is proximately due to, or the result of, or aggravated by a service-connected disease or injury. Establishing service connection on a secondary basis requires: (1) Competent evidence (a medical diagnosis) of a current disability (for which secondary service connection is sought); (2) evidence of a service connected disability; and (3) competent evidence that the current disability was either (a) caused or (b) aggravated by the service connected disability. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995)(en banc). Effective October 10, 2006, 38 C.F.R. § 3.310 was revised to implement the Allen decision. The revised 38 C.F.R. § 3.310 institutes additional evidentiary requirements that must be satisfied before aggravation may be conceded and service connection granted. In essence, it provides that in an aggravation secondary service connection scenario, there must be medical evidence establishing a baseline level of severity of disability prior to when aggravation occurred, as well as medical evidence showing the level of increased disability after aggravation occurred. As the Veteran's claim was pending prior to the effective date of the revised 38 C.F.R. § 3.310, the Board will consider the version in effect prior to October 10, 2006, as it is more favorable to the claimant. See Kuzma v. Principi, 341 F. 3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). As a preliminary matter, it is not in dispute that the Veteran has made competent statements indicating that he experiences the symptoms of tinnitus (subjective ringing in the ears), and a current diagnosis of tinnitus is accepted by the Board for the purposes of this analysis. What he must still show to establish service connection for his tinnitus is that such is related to his service and/or was caused or aggravated by a service-connected disability. The Veteran's STRs, including his June 1971 service separation physical examination report, are silent for any complaints, findings, treatment, or diagnosis related to tinnitus. Consequently, service connection for tinnitus on the basis that such disability became manifest in service and persisted is not warranted. Notably, the Veteran does not argue that his tinnitus is directly related to his service. The Veteran does not contend that he experienced tinnitus during service; the June 2008 VA examination report shows that he clearly recalled that his tinnitus began in approximately 2003 ("His history is that he had developed this approximately 5 years ago while working in a newsroom. He was required to wear earphones. Apparently, there was some noise there...."). The Veteran also does not contend that he was exposed to any pertinent acoustic trauma or injury to the ears during service, as explained in the June 2008 VA examination report ("When he was in the military, he was a food inspector. There was apparently no significant noise exposure"). The Veteran contends that his tinnitus is secondary to service-connected diabetes pathology, to specifically include his past use of aspirin in treating peripheral vascular disease associated with his diabetes; this contention is explained in the June 2008 VA examination report's summary of the Veteran's assertions at that time. The Veteran's theory of entitlement in this matter is strictly one of secondary service connection; he alleges that his tinnitus is due to his service-connected diabetes mellitus. As noted above, there are three requirements that must be met to substantiate a claim of secondary service connection. Of these, it is shown that the Veteran has tinnitus. Therefore, there is competent evidence of a current disability for which service connection is sought. He also has a service-connected disability, diabetes mellitus. What he must still show to substantiate this claim is that the service-connected diabetes mellitus caused or aggravated the tinnitus. The question of determining whether the Veteran's tinnitus has been caused or aggravated by his diabetes, or any associated medication or complication, is a medical question requiring medical training and expertise to provide competent evidence. There is no medical opinion nor any other competent evidence of record indicating that the Veteran's tinnitus has been caused or aggravated by his diabetes mellitus or any associated medication or complication. Significantly, the medical opinion of record most directly addressing this essential medical question in this appeal weighs against the Veteran's claim. In support of his claim, the Veteran has submitted a copy of an article from the website WebMD (printed in December 2007) which broadly discusses tinnitus. Most pertinently, the article indicates that tinnitus may in some cases be a side effect of aspirin or may be a symptom of diabetes (among a number of other possible causes and with a note that in many instances the cause of a specific case of tinnitus may never be found). Although this evidence establishes that in some cases tinnitus may be a side effect of aspirin use or a symptom associated with diabetes, it does not establish any probability that the Veteran's specific case of tinnitus is actually attributable to his diabetes or aspirin, or attributable to other possible causes, or may be among the common instances of tinnitus with no identifiable cause. The Veteran also submitted information from the American Tinnitus Association which primarily discusses tinnitus in Veterans due to noise exposure and does not discuss diabetes or aspirin. The evidence submitted by the Veteran in support of his claim contains a general discussion of potentially related medical issues in a general context, but does not address the Veteran's own clinical medical history, his postservice noise exposure history (including his work in a radio newsroom involving headphone use), or other details of this specific case on appeal. The evidence does not otherwise provide information that may otherwise be sufficient to serve as the basis for a grant of service connection in this case. Although such evidence may suggest that it is generally possible for tinnitus to be in some manner related to diabetes (or aspirin use) in some cases, service connection for this specific Veteran's case may not be based on a resort to speculation or mere possibility. See 38 C.F.R. § 3.102. In light of the evidence of record indicating that in some cases tinnitus may be attributable to diabetes (or associated aspirin use), the Veteran was afforded a VA examination to evaluate the nature and etiology of his tinnitus in connection with this appeal. A VA examination addressing the tinnitus issue was conducted in June 2008. The report of this June 2008 VA examination is of record, as is a July 2008 addendum providing the examiner's pertinent medical opinion. Following examination and interview of the Veteran, discussion of his pertinent history, and explanation of pertinent factors, the examining VA otorhinolaryngologist concluded that it is unlikely that the Veteran's tinnitus is secondary to his diabetes. The examiner's rationale cited that "the relationship between diabetes and tinnitus is not well established." The examiner further concluded that the use of aspirin is "not as likely as not" the cause of the Veteran's ongoing tinnitus, citing the fact that the Veteran had discontinued the use of aspirin. The examiner also concluded that the Veteran's peripheral vascular disease is not the cause of the Veteran's tinnitus. The Board finds that the June 2008 VA examination report, with the July 2008 addendum, is adequate and probative evidence pertinent to the tinnitus issue on appeal. The report presents the conclusions of a competent medical expert, informed of the pertinent facts through acceptance of the Veteran's own account of history in direct interview, with the benefit of direct examination, and the conclusions are explained with adequate rationales. The examiner acknowledges some medical possibility that diabetes "may be a factor" in some cases of tinnitus, but explains that there is insufficient basis for finding such a link in this case, in part due to the "not well established" nature of a medical relationship between diabetes and tinnitus generally. The examiner also acknowledges the possible significance of the Veteran's past use of aspirin (which the WebMD article suggests may cause tinnitus as a "side-effect," but does not clearly discuss as a cause of chronic tinnitus), but finds it unlikely that the Veteran's current tinnitus is etiologically linked to aspirin in light of the fact that the tinnitus has persisted long after the Veteran discontinued use of aspirin. The Board notes that there is no competent evidence of record that contradicts any of the factual or medical findings presented by the June 2008 VA examination report; no evidence of record indicates contrary information about the state of medical knowledge on these pathologies, and no evidence of record presents a competent opinion suggesting that the Veteran's case of tinnitus is actually caused or aggravated by his diabetes (or associated aspirin use). The Board has reviewed the entirety of the Veteran's VA medical records and finds no further evidence supportive of the Veteran's claim. The Board notes that a February 2005 VA Compensation and Pension examination report evaluating his diabetes documents the Veteran's complications of diabetes at that time, documents that the Veteran was taking aspirin for treatment at that time, and provides no suggestion that any complication of the diabetes (or associated medication) involved tinnitus. A February 2008 VA treatment record shows that the Veteran complained of tinnitus that "started couple yrs ago." This report notes that the Veteran wore headphones during his work in broadcasting. The report indicates that the tinnitus worsened during the previous Fall with "unknown cause" but "has been getting better in the past 3 weeks." The Veteran had recently discontinued his aspirin treatment due to his research indicating that aspirin could cause tinnitus. However, the VA medical provider (a physician's assistant whose assessment was reviewed by an otorhinolaryngologist) recommended that the Veteran resume taking the aspirin dosage as before; this evidence suggests that the trained medical professionals did not believe that the Veteran's aspirin use was causing or permanently aggravating his case of tinnitus. The evidence of record contains no competent indication that the Veteran's diabetes has caused or permanently aggravated his tinnitus. Similarly, the evidence of record contains no suggestion that use of aspirin or other pertinent medication has caused or aggravated the Veteran's chronic tinnitus. The June 2008 VA examination report addresses (in the July 2008 addendum) the Veteran's contentions with a conclusion that the Veteran's case of diabetes and its associated medication is less likely than not the cause of his tinnitus. The June 2008 VA examination report also describes that the Veteran's tinnitus, by his own account, has been improving since onset: "tinnitus was particularly bothersome to him when he first noticed it.... his tinnitus has become significantly less. It was bothering him at night.... That problem is apparently long gone." Thus, the history of the tinnitus symptomatology does not reflect that a service connected disability (to include associated medications) could have permanently aggravated his tinnitus, as the Veteran has not experienced a permanent increase in the severity of his tinnitus since the time of its original onset. There is simply no competent evidence to support the Veteran's contention that his tinnitus is caused or aggravated by his diabetes mellitus or any associated complication or medication. The Veteran's own statements relating his tinnitus to his service-connected diabetes mellitus are not competent evidence, as he is a layperson, and lacks the training to opine regarding medical etiology; whether one disability causes or permanently aggravates another is ultimately a medical question not capable of resolution by lay observation. See Jandreau v. Nicholson, 492 F. 3d. 1372 (Fed. Cir. 2007) (Whether lay evidence is competent and sufficient in a particular case is a fact issue to be addressed by the Board rather than a legal issue to be addressed by the Veterans' Court). Regarding the lay assertions that the Veteran's tinnitus is etiologically linked to his diabetes, the Board acknowledges that the lay statements are competent to testify as to symptoms the Veteran experiences, including the presence of tinnitus. See Barr v. Nicholson, 21 Vet. App. 303 (2007). However, as a layperson, the Veteran is not competent to establish an etiological link between two internal pathologies by his own opinion. As is explained above, the competent (medical) evidence of record does not support finding an etiological link between the tinnitus and the diabetes. As there is no competent evidence indicating that the Veteran's tinnitus has been caused or aggravated by his military service or by any service-connected disability, he has failed to establish any manner of nexus that might permit a grant of service connection for tinnitus in this case. In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran's claim of service connection for tinnitus. Accordingly, it must be denied. ORDER Service connection for tinnitus is denied. REMAND The Veteran seeks increased ratings for peripheral neuropathy of his lower extremities. The February 2011 VA compensation and pension examination report addressing the peripheral neuropathy issues explains that the disability is manifested by progressive "tingling in his toes bilaterally" and numbness in the lower extremities. The February 2011 VA examiner's impression included a statement explaining that the peripheral neuropathy "continues to progress." New pertinent VA treatment records added to the claims-file following the Board's August 2011 remand include a reasonable indication that the Veteran's peripheral neuropathy of the lower extremities may have further increased in severity since the time of the Veteran's most recent compensation and pension examination on the matter; the Board notes that such an increase would be consistent with the nature of the pathology as described in the February 2011 VA examination report. Specifically, the Board notes that an October 2011 VA treatment report, added to the record (in Virtual VA) after the Board's most recent remand shows that the Veteran complained of increased tingling in his feet. Testing revealed that neuro-protective sensation was absent with 5.07 Semmes Weinstein monofilament. The VA physician recommended that the Veteran return for follow-up evaluation in six months. The evidence reasonably suggests an increase in the severity of the progressive disability since the most recent VA examination (nearly two years ago). Accordingly, another examination is warranted. See 38 C.F.R. § 3.159; see also VAOPGCPREC 11-95 (1995) (a new examination is appropriate when there is an assertion of an increase in severity since the last examination). The Board also observes that a February 2012 VA treatment record (found in Virtual VA) states that the Veteran showed his primary care physician "documentation of prior three part diabetic foot exam, done elsewhere within last 12 months. The exam included visual exam, pulse exam, and sensation exam with monofilament device." The summary goes on to identify that the date of the referenced examination was "November 18, 2011," and that the results were "Abnormal." Although a pertinent October 2011 VA treatment report is available for review in Virtual VA, the Board has been unable to locate for review the discussed diabetic foot examination report from November 18, 2011. A number of other VA treatment reports from November 18, 2011 are available for review in Virtual VA, but these do not include any apparent diabetic foot examination report as described above. The Board observes that at least one of the November 18, 2011 treatment reports indicates that some test results were posted in CPRS (Computerized Patient Record System); it is unclear if the apparently missing diabetic foot examination results may also be posted in CPRS (which is not accessible to the Board) and not yet included in the claims-file. As the referenced November 18, 2011 diabetic foot examination report would be pertinent evidence in this appeal, steps must be taken to determine its availability and, if it is available to associate the report with the record for the Board's review. The Veteran also seeks to establish entitlement to a TDIU rating for the period prior to July 20, 2010. That matter is inextricably intertwined with the appeals seeking increased ratings; hence, consideration of the matter must be deferred pending resolution of those claims. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together). Regarding the TDIU issue, the Board's August 2011 remand directed that the RO should secure a medical opinion "which addresses the combined impact of the Veteran's service-connected disabilities on his employability prior to July 20, 2010." It does not appear that this development has been completed. In Stegall v. West, 11 Vet. App. 268, 271 (1998), the United States Court of Appeals for Veterans Claims (Court) held that a remand by the Board confers on the appellant, as a matter of law, the right to compliance with the remand orders. The Board notes that in a September 2011 letter the RO requested that the Veteran submit copies of his tax returns from the period for which he seeks a TDIU rating, and that he has not submitted such evidence. Under the circumstances of this case, the Board finds it reasonable to afford the Veteran another opportunity to respond to the RO's request during the processing of this remand. The Veteran is advised that a governing regulation provides that where evidence requested in connection with a claim for VA benefits is not received within a year of the request, the claim is to be considered abandoned. 38 C.F.R. § 3.158(a). As was discussed in the Board's August 2011 remand, a February 2011 VA compensation and pension examination report includes the physician's opinion that the Veteran's "peripheral neuropathy of the lower extremities renders him unemployable for sedentary or physically active work." The VA physician states this conclusion unequivocally: "the veteran's unemployability, as described, is caused by his diabetic peripheral neuropathy. He is unable to sustain sedentary or active ambulatory employment for the periods of time necessary to be gainfully employed." The Veteran has suggested, in various statements of record, that his peripheral neuropathy of the lower extremities diminished his ability to perform his job responsibilities to the point that he became unable to continue with full time employment in 2003. In light of these allegations, the possibility of referral for extraschedular must be considered. See 38 C.F.R. § 3.321(b)(1); see also Thun v. Peake, 22 Vet. App. 111 (2008). This matter must be addressed on remand. An extraschedular rating under 38 C.F.R. § 3.321(b)(1) is based on the fact that the schedular ratings are inadequate to compensate for the average impairment of earning capacity due to the Veteran's disabilities. Exceptional or unusual circumstances, such as frequent hospitalization or marked interference with employment, are required. See also Thun v. Peake, 22 Vet. App. 111 (2008). The Board is not authorized to assign an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; the proper course is to refer the matter to the Director of Compensation and Pension Service. Accordingly, the case is REMANDED for the following: 1. The RO should secure for the record copies of the complete updated (since May 2012) clinical records of any VA treatment or evaluation the Veteran has received for peripheral neuropathy of the lower extremities. 2. The RO should also take appropriate steps to associate with the claims-file any outstanding VA diabetic foot examination report from November 18, 2011. A February 2012 VA treatment report of record describes an "abnormal" November 18, 2011 VA diabetic foot examination report with potentially pertinent findings; the Board could not locate such a report in the claims-file or in Virtual VA. The RO should obtain any pertinent computerized patient record system (CPRS) reports from November 18, 2011 diabetic foot examination testing. If the RO determines that a November 18, 2011 VA diabetic foot examination report does not exist or cannot be associated with the claims-file, this finding (with explanation) should be formally documented in the claims-file. 3. The RO should also arrange for a neurological examination of the Veteran to assess the current severity of his right and left lower extremity peripheral neuropathy. The Veteran's claims files must be reviewed by the examiner in conjunction with the examination. The examiner must describe all symptoms and functional limitations attributable to the peripheral neuropathy. The examiner must explain the rationale for all opinions offered. 4. The RO should again request (as the RO previously requested in a September 2011 letter) that the Veteran submit copies of his 2008, 2009, and 2010 tax returns which show his earned income in those years. The handling of this request should be in compliance with any Privacy concerns raised. 5. A medical opinion should be secured regarding the combined impact of the Veteran's service-connected disabilities on his employability prior to July 20, 2010. The entire record must be reviewed by the physician who provides the medical opinion. The consulting physician must explain the rationale for all opinions. 6. The RO should arrange for any further development necessary to address the matters of entitlement to an extraschedular rating for the Veteran's peripheral neuropathy of both lower extremities (e.g., the associated impairment of function, and its effect on the Veteran's activities); the RO should note the February 2011 VA examination finding that the Veteran's peripheral neuropathy of the lower extremities alone renders him unemployable. Then, if indicated (i.e., if schedular criteria are deemed inadequate to rate the disability prior to July 20, 2010), the matter should be referred to the Director of Compensation and Pension for consideration of entitlement to an extraschedular rating. 7. The RO should then review the record, and readjudicate the increased rating claims and the TDIU (for the period prior to July 20, 2010) claim in light of all additional evidence received. With the Veteran's cooperation (by providing necessary information) the RO should fully develop and address the matter of whether the Veteran is entitled to a TDIU rating for the period prior to July 20, 2010. If any claim on appeal remains denied, the RO should issue an appropriate SSOC and afford the Veteran and his representative the opportunity to respond. The case should then be returned to the Board, if in order, for further review. The appellant has the right to submit additional evidence and argument on the 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 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). ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs