Citation Nr: 1301017 Decision Date: 01/10/13 Archive Date: 01/16/13 DOCKET NO. 12-20 095 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a bilateral hip disability. 2. Entitlement to service connection for peripheral neuropathy of the right upper extremity. 3. Entitlement to service connection for peripheral neuropathy of the left upper extremity. 4. Entitlement to service connection for residuals of cold injury of the upper extremities. 5. Entitlement to an initial rating in excess of 30 percent for Hepatitis C. 6. Entitlement to an increased rating in excess of 20 percent for peripheral neuropathy of the right lower extremity. 7. Entitlement to an increased rating in excess of 20 percent for peripheral neuropathy of the left lower extremity. 8. Entitlement to an increased rating in excess of 10 percent for the service-connected residuals of cold injury of the right foot. 9. Entitlement to an increased rating in excess of 10 percent for the service-connected residuals of cold injury of the left foot. 10. Entitlement to special monthly compensation based on the need for regular aid and attendance of another person or housebound status. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C.L. Krasinski, Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from August 1944 to July 1946. He was awarded a Combat Infantryman's Badge and he participated in campaigns in Rhineland, Ardennes, and Central Europe. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in January 2010, April 2010, and December 2010 issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. 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). The issues of service connection for a bilateral hip disability, peripheral neuropathy of the upper extremities, and residuals of cold injury of the upper extremities; and entitlement to higher ratings for Hepatitis C, peripheral neuropathy of the lower extremities, and residuals of cold injury of the feet are addressed in the REMAND portion of the decision below, and are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. The Veteran is shown to require the regular assistance of another person when caring for his daily personal needs of dressing, toileting, and cleaning as the result of his service-connected chronic vertigo, peripheral neuropathy of the right and left lower extremities, and the residuals of cold injury to the left and right feet. 2. The Veteran is not permanently housebound by reason of his service-connected disabilities and does not have a single disability rated as 100 percent disabling. CONCLUSIONS OF LAW 1. Affording the Veteran the benefit of the doubt, the criteria for establishing entitlement to special monthly compensation based on the need for aid and attendance have been met. 38 U.S.C.A. §§ 1114, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.350, 3.352 (2012). 2. The criteria for special monthly compensation based on being housebound due to a service-connected disability have not been met. 38 U.S.C.A. §§ 1114, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.350, 3.352 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's 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); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of the VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). A "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ), as was done in this case. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Regarding the claim for special monthly compensation based upon aid and attendance, to the extent that the action taken hereinbelow is favorable to the Veteran, further discussion of VCAA is not required at this time. Regarding the claim for special monthly compensation based upon housebound status, the Board concludes that the Veteran has been afforded appropriate notice under VCAA. The RO provided a VCAA notice letter to the Veteran in August 2010, prior to the initial adjudication of the claim. The letter notified the Veteran of what information and evidence must be submitted to substantiate the claim for special monthly compensation based upon aid and attendance and housebound status, as well as what information and evidence must be provided by the Veteran and what information and evidence would be obtained by VA. He was also told to inform VA of any additional information or evidence that VA should have, and was told to submit evidence in support of his claim to the RO. The content of the letter complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). The Board finds that all relevant evidence has been obtained with regard to the Veteran's claim, and the duty to assist requirements have been satisfied. VA treatment records also have been associated with the claims folder. The Veteran also underwent VA examinations in 2010. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the examination and opinion for this claim to be adequate. The examiner obtained a history from the Veteran, examined him, and reviewed the available pertinent records prior to rendering a medical opinion as to whether the Veteran required the aid and assistance of another or was housebound. The Board finds that an additional medical examination is not necessary. The record does not otherwise indicate any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Special Monthly Compensation: Legal Criteria Compensation at the aid and attendance rate is payable when the veteran, due to service-connected disability, has suffered the anatomical loss or loss of use of both feet or one hand and one foot, or is blind in both eyes, or is permanently bedridden or so helpless as to be in need of regular aid and attendance. 38 U.S.C.A. § 1114(l); 38 C.F.R. § 3.350(b). Determinations as to the need for regular aid and attendance are factual and must be based upon the actual requirements for personal assistance from others. In making such determinations, consideration is given to such conditions as: The inability of the claimant to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without assistance. The inability of the claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, either physical or mental, which requires care or assistance on a regular basis to protect a claimant from hazards or dangers incident to one's daily environment. It is not required that all of the disabling conditions enumerated be present before a favorable rating is made. The particular personal functions that the claimant is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the claimant be so helpless as to be in need of regular aid and attendance, not that there is a constant need. "Bedridden" constitutes a condition which, through its essential character, actually requires that an individual remain in bed. The fact that a claimant has voluntarily taken to bed, or that a physician has prescribed bed rest for a lesser or greater portion of the day will not suffice. 38 C.F.R. § 3.352(a). In Turco v. Brown, 9 Vet. App. 222, 224 (1996), the U.S. Court of Appeals for Veterans Claims (Court) held that eligibility for special monthly compensation by reason of regular need for aid and attendance requires that at least one of the factors set forth in VA regulation is met. In addition, determinations that the claimant is so helpless as to be in need of regular aid and attendance will not be based solely upon an opinion that the claimant's condition is such as would require him or her to be in bed. They must be based on the actual requirement of personal assistance from others. See Turco, 9 Vet. App. at 224. The evidence must show that the claimant is so helpless as to need regular and attendance; constant need for aid and attendance is not required. 38 C.F.R. § 3.352(a). 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 veteran. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), it was observed that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." Analysis of SMC The Veteran contends that special monthly compensation is warranted because he requires the regular aid and attendance of another person for assistance with dressing or undressing himself, toileting, and keeping himself clean and presentable. He also points out that he ambulates with a cane or walker due to his service-connected disabilities. The Veteran has been granted service connection for peripheral neuropathy of the left lower extremity rated as 20 percent disabling; peripheral neuropathy of the right lower extremity rated as 20 percent disabling; residuals of cold injury of the left foot rated as 10 percent disabling, residuals of cold injury of the right foot rated as 10 percent disabling, chronic vertigo rated as 30 percent disabling; hepatitis C rated as 30 percent disabling, and bilateral hearing loss rated as 60 percent disabling. The Veteran's combined total rating is 90 percent, and he was assigned a total rating based upon individual unemployability by reason of service-connected disability, effective on August 21, 2006. SMC based on Need for Aid and Attendance The Board finds that the evidence is in equipoise on the question of whether the Veteran requires the regular aid and attendance of another person for dressing or undressing himself, toileting, and keeping himself clean and presentable as the result of his service-connected disabilities alone. He is shown to receive help with toileting, bathing and dressing due to vertigo and imbalance. The Veteran is shown to experience limited mobility and ability to ambulate with a cane or walker due to his service-connected disabilities. The October 2010 VA aid and attendance examination report indicates that the Veteran's spouse helped him to get out of bed in the morning and into a wheel chair to go to the bathroom. The Veteran's spouse helped him to the toilet and into the shower. The Veteran sat on a chair in the shower and his spouse helped bath him. The Veteran's spouse also helped him to dress. It was noted that the self care skills the Veteran was not able to perform included dressing and undressing and bathing. Physical examination revealed that the Veteran required a cane for ambulation. There was muscle weakness in the left and right lower extremities. The Veteran had abnormal propulsion and needed a cane. He had abnormal balance and could not stand unassisted. The October 2010 VA cold injury examination report indicates that upon examination, the Veteran had a shuffling gait. The diagnosis was residuals of cold injury and peripheral neuropathy of the bilateral lower legs and feet. The examiner indicated that the Veteran had decreased mobility, problems with lifting and carrying, and decreased strength of the lower extremities. Regarding the effect on the activities of daily living, the examiner indicated that the Veteran was unable to do house chores or go to the grocery, and he needed assistance with dressing, bathing, getting up from the toilet, and cutting his meat. The October 2010 VA peripheral nerves examination indicates that the Veteran used a wheel chair at home and used an electric scooter outside the home. The report indicates that the peripheral nerves symptoms affected both feet and the Veteran had numbness in both feet. Examination revealed that the Veteran had a slow gait and he used a cane for assurance. He had a slight tremor when standing. The examiner indicated that the decreased mobility and imbalance due to the peripheral neuropathy of the bilateral lower legs and feet affected the Veteran's usual daily activities. An August 2010 VA primary care record indicates that the Veteran had numbness in the extremities and his balance problem persisted. The Veteran was now getting electrical stimulation. He reported that he did not have any falls. It was noted that he used an electric wheel chair at home and he needed help getting out of the shower, toileting, and grooming. The Veteran used a walker outdoors. It was noted that he was no longer driving. VA treatment records dated in November 2011 and April 2012 indicate that the Veteran's balance was worsening. The November 2011 VA treatment record notes that the Veteran used an electric scooter at home and he needed help with the shower, toilet, and grooming. There is medical evidence that the Veteran does not need assistance with activities of daily living. For instance, an August 2011 VA treatment record notes that the Veteran was independent in activities of daily living. On this record, the Board finds that the evidence is in equipoise on the question of whether the Veteran requires the regular aid and attendance of another person for dressing or undressing himself, toileting, and keeping himself clean and presentable as the result of the service-connected vertigo, peripheral neuropathy of the lower extremities, and residuals of cold injury to the feet. It is not required that all of the disabling conditions enumerated in 38 C.F.R. § 3.352(a) be found to exist before a favorable rating may be made. It is logical to infer, however, a threshold requirement that "at least one of the enumerated factors be present." Turco at 224. The performance of the necessary aid and attendance service by a relative or other member of the household will not prevent the granting of the additional allowance. 38 C.F.R. § 3.352(c). Thus, on this record, affording the Veteran the benefit of the doubt, the Board finds that the claim for special monthly compensation based on the need for regular aid and attendance is warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. SMC based on Housebound The regulations also provide additional compensation on the basis of being housebound where the veteran (1) has, in addition to a single, permanent service-connected disability rated 100 percent disabling, additional service-connected disability or disabilities independently evaluated as 60 percent or more disabling which are separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. A veteran will be considered housebound where the evidence shows that, as a direct result of his service-connected disability or disabilities, he is substantially confined to his dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his lifetime. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350. Regarding the criteria necessary for housebound status, the Veteran does not have a single, permanent service-connected disability rated 100 percent disabling; therefore, he does not meet the legal criteria for payment of compensation at the housebound rate under that criterion. See 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350. Furthermore, as detailed above, the competent evidence does not show that the Veteran's service-connected disabilities resulted in the Veteran being housebound. The evidence of record shows that the Veteran is able to ambulate with a cane or walker and is able to leave his home with use of a scooter, cane, walker, or wheel chair. There is no evidence showing that the Veteran is bedridden. The record shows that he is able to leave his house for medical appointments. Therefore, the Veteran does not qualify for special monthly compensation by reason of being housebound due to service-connected disability. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the fair preponderance of the evidence is against the claim, in which case, the claim is denied. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. The Board finds that, because there is a preponderance of the evidence against the claim for special monthly compensation based upon being housebound, reasonable doubt is not for application, and this claim must be denied. ORDER Special monthly compensation based on the need for regular aid and attendance is granted. Special monthly compensation based on housebound status is denied. REMAND The VCAA specifically provides that the duty to assist includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002). Initial Rating for Hepatitis C The Veteran asserts that the service-connected hepatitis C has worsened since service connection was granted in January 2010 and the 30 percent was assigned from December 2, 1997. A June 2010 record from the Veteran's private physician indicates that the Veteran's hepatitis C turned into stage 4 cirrhosis with high liver function tests. Because of the evidence of possible worsening, a new examination is needed to determine the severity of the hepatitis C. Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95. Service Connection for Bilateral Hip Disorder The Veteran also asserts that he incurred a current bilateral hip disorder due to medication for the hepatitis C. The Veteran submitted medical evidence showing a diagnosis of mild avascular necrosis of the left hip and significant avascular necrosis of the right hip. The treatment record noted that the Veteran has a history of hepatitis C and, in 1998, he was required to undergo about eight months of high dose steroids. Thus, the Board finds that an examination is needed to assist in determining whether the claimed bilateral hip disability is proximately due to or aggravated by the service-connected hepatitis C and whether it is otherwise related to disease or injury in service. Increased Ratings for Peripheral Neuropathy and Cold Residuals of the Feet The Veteran asserts that the service-connected peripheral neuropathy of the lower extremities and cold residuals of the feet may have worsened. The Veteran was afforded a VA examination in October 2010. In a December 2010 statement, the Veteran indicated that the medication for the peripheral neuropathy, garapentin, was increased from 900 milligrams to 1500 milligram. He stated that this was done for the peripheral neuropathy of the feet and legs, and these disorders were getting worse. An August 2011 VA neurology clinic record shows that the dose of the gabapentin was increased from 300 milligrams to 600 milligrams. Because of the evidence of possible worsening since the last examination in October 2010, a new examination is needed to assist in determining the severity of the peripheral neuropathy of the lower extremities and residuals of the cold injury to the feet. The Veteran and his representative argue that the October 2010 VA examination report was inadequate because the examiner was not a board certified neurologist. See the Veteran's statements dated in November 2010 and July 2011 and the representative's statement dated in September 2012. VA satisfies its duty to assist when it provides a medical examination performed by a person who is qualified through education, training, or experience to offer medical diagnosis, statements, or opinions able to provide competent medical evidence, whether that is a doctor, nurse practitioner or physician's assistant. Cox v. Nicholson, 20 Vet. App. 563, 569 (2007). In the present case, the Board finds that the examiner is qualified as a trained medical doctor to conduct the VA examination; however, the October 2010 examination is not adequate for other reasons. The VA examiner did not render an opinion as to the degree of the severity of the peripheral neuropathy of the lower extremities, and the examination report did not contain sufficient details for rating purposes. See 38 C.F.R. § 4.2 (2012); Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); Ardison v. Brown, 6 Vet. App. 405, 407 (1994). VA is required to conduct an accurate and descriptive medical examination based on the complete medical record. 38 C.F.R. §§ 4.1, 4.2 (2012); Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA's duty to assist includes "the conduct of a thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one"). Thus, the Board finds that an examination is needed to obtain evidence as to the current severity of the peripheral neuropathy of the left and right lower extremities, and the residuals of cold injury to the left and right feet. Service Connection for Peripheral Neuropathy and Cold Injury to the Hands Regarding the claims for service connection for peripheral neuropathy of the upper extremities and residuals of cold injury to the left and right hands, the Board finds that an additional medical examination is necessary. The Veteran was afforded a VA examination in October 2010. The VA examiner provided a medical opinion as to whether the peripheral neuropathy of the upper extremities was secondary to the service-connected peripheral neuropathy of the lower extremities; however, the examiner did not provide a medical opinion as to whether the peripheral neuropathy and residuals of cold injury of the upper extremities were related to service, specifically the cold injury in service. The record shows that the Veteran served in central Europe in World War II and was exposed to extreme cold. Service connection for cold injuries to the feet is currently in effect. Thus, the Board finds that an examination is needed to assist in determining whether the claimed peripheral neuropathy and cold injuries to the bilateral upper extremities and hands are due to injury or other event or incident in active service to include the exposure to extreme cold during service in World War II. Treatment Records The RO should contact the Veteran by letter and ask him to provide sufficient information and necessary authorization so that the RO may make an attempt to obtain treatment records referable to treatment for the claimed bilateral hip disability and the claimed peripheral neuropathy of the upper extremities and residuals of cold injury of the left and right hand, and any treatment for the service-connected hepatitis C, peripheral neuropathy of the left and right legs, and residuals of cold injury to the left and right feet. The RO should ask the Veteran to provide sufficient information, and if necessary authorization, to enable the RO to obtain any pertinent VA or non-VA treatment records showing treatment of the claimed disabilities and the service-connected disabilities. The Veteran should be asked to provide the necessary information and authorizations for Dr. Fernando Norona of the Neurological Disorders Clinic, P.A., in Boca Raton, Florida and for Dr. Wisam Zakko of the Gastroenterology Institute of Fort Lauderdale. In addition, the RO should also obtain the VA treatment records dated for the claimed disabilities and the service-connected disabilities since May 2012. VA has a duty to seek these records. 38 U.S.C.A. § 5103A(b)(1). 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 should take all indicated action in order to obtain copies of the Veteran's VA treatment records dated since May 2012 from the VA healthcare system in Florida. 2. The RO should take appropriate steps to contact the Veteran and ask him to provide sufficient information and necessary authorization in order to obtain copies of any outstanding records of treatment by VA or non-VA health care providers for the claimed disabilities and the service-connected peripheral neuropathy of the lower extremities, the residuals of cold injuries to the feet, and Hepatitis C. The Veteran should be asked to provide the necessary information and authorization for Dr. Fernando Norona of the Neurological Disorders Clinic, P.A., in Boca Raton, Florida and for Dr. Wisam Zakko of the Gastroenterology Institute of Fort Lauderdale. If the Veteran provides the necessary information and authorizations, the RO should obtain legible copies of any outstanding clinical records and incorporate them into the claims file. 3. The RO should schedule the Veteran for a VA examination to assist in determining the current severity of the service-connected Hepatitis C, and to obtain a medical opinion as to whether the Hepatitis C caused or aggravated the bilateral hip disorder. The relevant documents in the Veteran's VA claims folder should be made available to the examiner for review in connection with the examination. All indicated tests should be performed. The VA examiner should specifically note all symptomatology and manifestations caused by the service-connected Hepatitis C. The VA examiner should indicate whether the Hepatitis C causes daily fatigue, malaise, anorexia, minor or substantial weight loss or other sign of malnutrition, hepatomegaly, dietary restriction, continuous medication, or incapacitating episodes. The examiner should report whether the symptoms are intermittent or near-constant and debilitating. If the hepatitis C causes incapacitating episodes (a period of acute signs and symptoms severe enough to require bed rest and treatment by a physician), the examiner should note the frequency and duration of the episodes in the past 12 months. The examiner should report whether the incapacitating episodes cause symptoms of fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain. The examiner should provide the following medical opinions: Is it at least as likely as not (50 percent probability or more) that the claimed bilateral hip disability to include avascular necrosis is caused by the service-connected Hepatitis C (including medications used to treat the hepatitis C)? Is it at least as likely as not (50 percent probability or more) that the claimed bilateral hip disability to include avascular necrosis is aggravated by the service-connected Hepatitis C (including medications used to treat the hepatitis C)? If the examiner concludes that the bilateral hip disorder was aggravated by the service-connected Hepatitis C, the examiner should indicate the degree of disability due to the aggravation. Aggravation means a permanent worsening in severity of disability beyond a normal progression. Is it at least as likely as not (50 percent probability or more) that the claimed bilateral hip disability to include avascular necrosis is caused by any injury or event in active service? A rationale should be provided for all findings and conclusions reached. The examiner should identify and explain the medical basis for any opinion and identify the pertinent evidence of record. 4. The RO should schedule the Veteran for a VA neurological examination to assist in determining the current severity of the service-connected peripheral neuropathy of the lower extremities and the service-connected residuals of cold injury to the bilateral feet and to obtain a medical opinion as to the etiology of the claimed peripheral neuropathy of the bilateral upper extremities and residuals of the cold injury to the hands. The relevant documents in the Veteran's VA claims folder should be made available to the examiner for review in connection with the examination. All indicated tests should be performed. The VA examiner should specifically note all symptomatology and manifestations caused by the service-connected peripheral neuropathy of the lower extremities. The examiner should specify whether the peripheral neuropathy of the lower extremities is mild, moderate, moderately-severe, or severe. The examiner should report whether there is complete paralysis in the leg and foot due to the peripheral neuropathy and whether there is evidence of foot drop and/or a loss of movement or weakened movement below the knee and in the foot and ankle. The VA examiner should describe all signs and symptoms associated with the Veteran's residuals of cold injury of the feet. The examiner should specific comment whether the Veteran's cold injury residuals have resulted in any associated arthralgia or other pain, numbness, cold sensitivity, tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, or X-ray abnormalities. Any opinions provided by the examiner should include a rationale which reflects consideration of both the medical and lay evidence of record. The examiner should identify and explain the medical basis for any opinion and identify the pertinent evidence of record. The examiner should render the following opinions: Does the Veteran have current diagnosed disabilities of peripheral neuropathy of the upper extremities and residuals of cold injury of the hands? If so, is it at least as likely as not (50 percent or greater probability) that any current diagnoses of peripheral neuropathy of the upper extremities and residuals of cold injury of the hands are caused by or related to injury or other event during active service, including cold exposure during World War II? The VA examiner should outline the rationale for any opinion expressed. If any requested medical opinion cannot be given, the examiner should state the reason(s) why. 5. After completing the requested action, and any additional notification and/or development deemed warranted, the RO should readjudicate the claims remaining on appeal in light of all evidence of record. If any benefit sought on appeal remains denied, the RO should furnish a fully responsive Supplemental Statement of the Case to the Veteran and his representative and afford them a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran 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). The Veteran is advised to appear and participate in any scheduled VA examination(s), as failure to do so may result in denial of the claim(s). See 38 C.F.R. § 3.655 (2012). 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). ______________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs