Citation Nr: 1302010 Decision Date: 01/17/13 Archive Date: 01/23/13 DOCKET NO. 08-36 434 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a back disability, to include lumbar spine spondylosis and thoracic dextroscoliosis. 2. Entitlement to service connection for a right upper extremity neurological disability. 3. Entitlement to service connection for a right lower extremity neurological disability, to include as secondary to a back disability. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L.M. Yasui, Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from April 1981 to July 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. In August 2011, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is associated with the claims file. In November 2011, the Board remanded this matter to the RO via the Appeals Management Center (AMC) in Washington, DC for additional development. The case has been returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). Additional discussions regarding the RO's compliance with the November 2011 Board Remand are included in both the Duties to Notify and Assist and Remand sections below. Also, in the November 2011 decision, the Board remanded the claims for entitlement to service connection for a cervical spine disability, service connection for diverticulitis, and service connection for gastroenteritis. In October 2012, the RO fully granted service connection for a cervical spine disability and diverticulitis (also claimed as gastroenteritis). The RO indicated that the grant of service connection for diverticulitis encompassed both claims for service connection for diverticulitis and gastroenteritis as the VA examiner concluded that a prior diagnosis of gastroenteritis was actually diverticulitis. As such, the Veteran was informed that the October 2012 rating decision represented a total grant of the benefits sought on appeal for those issues; those issues are not in appellate status and are not before the Board. After reviewing the contentions and evidence of record, the Board finds that the issues on appeal are more accurately stated as listed on the title page of this decision. In evaluating this case, the Board has not only reviewed the Veteran's physical claims file, but has also reviewed the Veteran's file on the "Virtual VA" system to ensure a complete assessment of the evidence. The issues of entitlement to service connection for a back disability, to include lumbar spine spondylosis and thoracic dextroscoliosis, and service connection for a right lower extremity neurological disability, to include as secondary to a back disability 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. All relevant evidence necessary for an equitable disposition of the Veteran's appeal has been obtained. 2. The weight of the competent, probative evidence of record demonstrates that the Veteran does not have a current diagnosis of a right upper extremity neurological disability. CONCLUSION OF LAW The criteria for service connection for a right upper extremity neurological disability have not been met. 38 U.S.C.A. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The notice obligations of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The Board notes that 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). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In a timely letter dated in June 2006, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate a claim for service connection, as well as what information and evidence must be submitted by the Veteran, and what evidence VA would obtain. The notice included provisions for disability ratings and for the effective date of the claim. With regard to the duty to assist, VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records (as well as a separation report of medical examination obtained pursuant to the November 2011 Board Remand), post-service VA and private treatment records, a VA examination from December 2011, and the Veteran's statements. To that end, 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 VA opinions and findings obtained in this case are adequate as they pertain to the claim for service connection for a right upper extremity neurological disability. The VA opinion provided in December 2011, pursuant to the November 2011 Board Remand, considers all of the pertinent evidence of record, to include the statements of the Veteran, and provided a complete rationale for the opinion stated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue of a right upper extremity neurological disability has been met. 38 C.F.R. § 3.159(c)(4); see also Stegall v. West, 11 Vet. App. 268 (1998). As such, the RO has provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal, and has not argued that any error or deficiency in the accomplishment of the duty to assist has prejudiced him in the adjudication of his appeal. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006). Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claim. Service Connection - Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or the result of, a service-connected disease or injury. To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). A veteran as a lay person is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau at 1372). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Medical evidence that is speculative, general, or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). A physician's statement framed in terms such as "may" or "could" is not probative. See Warren v. Brown, 6 Vet. App. 4, 6 (1993). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal, 5 Vet. App. at 461 (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Service Connection for a Right Upper Extremity Neurological Disability The Veteran contends that he has a right upper extremity neurological disability that is related to his service. The Board finds that the weight of the competent, credible and probative evidence is against a finding of service connection for claimed right upper extremity neurological disability. The Veteran's service treatment records were negative for a diagnosis of a right upper extremity neurological disability in service. A May 1990 service treatment record revealed that the Veteran had weakness and aches in his extremities, among other extensive symptoms; however, the Veteran's symptoms were not attributable to any neurological disability as he was diagnosed with gastroenteritis and dehydration. Also, a November 1998 service treatment record indicated that the Veteran complained of pain in his shoulder and numbness in his right arm without weakness or tingling; however, upon examination, while he had a tender right shoulder, his upper extremity had full strength and his sensation was intact. The Board finds that the Veteran does not have a current diagnosis of a right upper extremity neurological disability. During an October 2008 VA examination, the examiner indicated that the Veteran complained of radiculopathy in his entire right arm and right lower extremity. It was also indicated that the radiculopathies do not increase with cough, laugh, sneeze or valsalva maneuver. Upon physical examination, the October 2008 examiner indicated that deep tendon reflexes of the bilateral upper extremities were +1 (hypoactive). However, he had full muscle strength of his upper extremities and neurosensory was intact distally to all digits of the upper extremities. Indeed, during the physical examination, the examiner noted that the Veteran had a subjective complaint of loss of sensation in the right lateral thigh, however, there was no subjective complaint of right upper extremity symptomatolgy noted. Although the October 2008 VA examiner diagnosed the Veteran with "subjective radiculopathy of right upper extremity," he found no objective findings of right upper extremity radiculopathy. Pursuant to the November 2011 Board Remand, the Veteran was afforded a VA examination of his nerves in December 2011. There, he complained of a shooting pain in his right upper extremity but denied upper extremity numbness. Upon physical examination, the December 2011 examiner indicated that there were no symptoms attributable to any peripheral nerve condition. The Veteran demonstrated normal muscle strength in his right elbow, wrist, grip, and pinch (thumb to index finger). He also had 2+ (normal) deep tendon reflexes of the right bicep, tricep, and brachioradialis. The results for sensation testing for light touch revealed a normal sensory examination of the right shoulder, inner/outer forearm, and hand/fingers. The December 2011 examiner clearly indicated that the Veteran had a normal right radial nerve, right median nerve, and right musculocutaneous nerve. Results from a magnetic resonance imaging (MRI) of the spine revealed no radiculopathy, which was verified by the interpreting radiologist. Based on the above objective testing, the December 2011 examiner concluded that there was no radiculopathy of the right upper extremity. Here, in weighing the evidence, the Board finds the December 2011 VA examination outweighs the October 2008 VA examination. To the extent that the October 2008 examiner noted a diagnosis of subjective radiculopathy of the right upper extremity, this finding has little probative value because it was based on the Veteran's subjective complaint of radiculopathy which is not supported by reported symptoms by the Veteran during the examination and by objective clinical findings made by the examiner during the conduct of the examination. In contrast, the Board finds the December 2011 VA examination to be more probative than the October 2008 examination on the issue of service connection as the examiner conducted diagnostic tests, to include tests for muscle strength, deep tendon reflexes, sensation, and an MRI. These findings were also supported by an interview with the Veteran, including his reported complaint of a shooting pain in his right upper extremity, and a complete examination of the Veteran. The December 2011 examiner relied on professional training and expertise, as well as a review of the Veteran's claims file, before determining that the Veteran did not have a currently diagnosed right upper extremity neurological disability. Regarding the Veteran's statements as to a diagnosis of a right upper extremity neurological disability, the Board recognizes that lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson, 581 F.3d at 1316 (Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). However, in this case, the diagnosis of the Veteran's subjective complaints of right upper extremity pain involves a complex medical etiological question as it deals with the origin and progression of the Veteran's right upper extremity neurological disability manifested by pain. The Veteran is competent to relate symptoms of a right upper extremity neurological disability that he experienced at any time, but is not competent to diagnose a right upper extremity neurological disability, as such diagnosis requires specific medical knowledge and training. See Rucker, 10 Vet. App. at 74 (stating that a lay person is not competent to diagnose or make a competent nexus opinion about a disorder as complex as cancer). For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for a right upper extremity neurological disability, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for a right upper extremity neurological disability is denied. REMAND Another remand is required in this case to ensure that there is a complete record upon which to decide the Veteran's claims of service connection for a back disability and a right lower extremity neurological disability, so that he is afforded every possible consideration. VA has a duty to make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a) (West 2002); 38 C.F.R. § 3.159(c), (d) (2012). Pursuant to the November 2011 Board Remand, the Veteran was afforded a VA examination of his back and nerves in December 2011. With respect to the Veteran's back, which includes the thoracic and lumbar spine, the Board finds the findings and opinions inadequate. The examination report indicated the Veteran's reported history of injuring his back while lifting a bomb and treatment with nonsteroidal anti-inflammatory drugs (NSAIDs). The December 2011 VA examiner noted a December 2004 radiology report, indicating that lateral views of the thoracic lumbar spine demonstrated mild dextroscoliosis of the thoracic spine centered around T4. While the examiner concluded that the Veteran did not have scoliosis of the lumbar spine, she did render a diagnosis of cervical thoracic dextroscoliosis (which she indicated was observed but not by definition). The VA examiner also diagnosed the Veteran with spondylosis of the lumbar spine. As to the etiology of the Veteran's back disabilities, to include lumbar spine spondylosis and thoracic dextroscoliosis, the VA examiner opined that the Veteran's lumbar spine disability is not caused by or a result of active duty. She explained that the Veteran's initial complaint was posterior right upper extremity on active duty and no evidence with links to the lumbar spine. The Board finds this rationale inadequate because the VA examiner did not address the Veteran's reported history of in-service injury to his back with NSAID treatment. The Board emphasizes that the Veteran is competent to describe the injury and treatment of his back experienced in service as well his in-service symptomatology. See Buchanan v. Nicholson, 451 F.3d 1331, 1336, 1337 (Fed. Cir. 2006); Dalton v. Nicholson, 21 Vet. App. 23 (2007). In addition, although the VA examiner diagnosed the Veteran with thoracic dextroscoliosis and concluded that cervical thoracic scoliosis is most likely associated with active duty aging, she did not opine as to whether the thoracic scoliosis preexisted his military service and was permanently aggravated therein, as clearly instructed by the Board in the November 2011 Remand. A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). Failure of the Board to ensure compliance with remand instructions constitutes error and warrants the vacating of a subsequent Board decision. Id. Therefore, pursuant to Stegall, the case must again be remanded for compliance with the November 2011 Board Remand and an adequate medical opinion must be obtained as to the etiology of the Veteran's back disability, to include lumbar spine spondylosis and thoracic dextroscoliosis. With respect to the claim for service connection for a right lower extremity neurological disability, to include as secondary to a back disability, the Board finds that the December 2011 examination is inadequate. The December 2011 VA examiner ultimately concluded that there was no radiculopathy found of the lower extremity and as such, she did not provide a medical opinion. The Board notes, however, that the Court of Appeals for Veterans Claims has held that a current disability exists if the diagnosed disability is present during the pendency of the claim, even if the disability resolves prior to adjudication. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). A July 2008 private treatment report indicated that the Veteran complained of lumbar radiculopathy and back pain. Magnetic resonance imaging (MRI) results revealed findings of "[r]ight paracentral disc extrusion L5-S1 with mass effect upon the traversing right S1 nerve root. Correlate with right lower extremity radiculopathy." In October 2008, the Veteran underwent a VA examination. At that time, he was diagnosed with meralgia paresthetica of the right thigh. No opinion regarding the etiology of the right thigh meralgia paresthetica was provided at that time. In contrast to this evidence of record, the December 2011 VA examiner indicated in the examination report that there were no other significant diagnostic test findings and/or results. As the Veteran submitted his claim for service connection for a neurological disability in May 2005 and he was diagnosed with a right lower extremity neurological disability during the pendency of his claim, a medical opinion is necessary to determine the etiology of that right lower extremity neurological disability, to include whether it is secondary to a back disability. Finally, as discussed above, under VCAA, 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The RO provided VCAA notice prior to adjudicating the issue on appeal regarding service connection for a right lower extremity neurological disability. However, as the Veteran is also asserting secondary service connection, a revised VCAA notice that outlines the means by which to establish service connection on a secondary basis must be provided. See 38 C.F.R. § 3.310 (2012); Allen v. Brown, 7 Vet. App. 439 (1995). Accordingly, the case is REMANDED for the following action: 1. Ensure compliance with all VCAA notice and assistance requirements. Specifically, provide the Veteran with notice regarding the requirements for substantiating a claim for service connection for a disability as secondary to an already service-connected disability. 38 U.S.C.A. §§ 5103 and 5103A (West 2002 & Supp. 2011). 2. If possible, request that the medical professional who conducted the December 2011 VA examination review the claims file and provide an addendum medical opinion. The claims file, including a copy of this Remand, must be made available to, and be reviewed by, the examiner. The examiner should note such review in the examination report (another examination of the Veteran is not required). The examiner should offer the following opinions: a) Is there clear and unmistakable evidence (i.e., obvious and manifest, which is a very high likelihood, much greater than a 50-50 degree of probability) that the Veteran had thoracic dextroscoliosis, which pre-existed his entrance into military service in April 1981? b) If it is the examiner's opinion that there was thoracic dextroscoliosis which preexisted the Veteran's entrance into military service, the examiner should offer the following opinion: Is there clear and unmistakable evidence (as above, obvious and manifest) that the preexisting thoracic dextroscoliosis was not aggravated during service? Note: The term "aggravated" in this context refers to a permanent worsening of the underlying condition during service, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. c) If it is the examiner's opinion that the Veteran's thoracic dextroscoliosis did not preexist service, the examiner should offer the following opinion: Is it at least as likely as not (50 percent probability or greater) that any current disability of the back, to include lumbar spine spondylosis and thoracic dextroscoliosis, began during service or is otherwise etiologically linked to some incident of active duty? In rendering this opinion, the examiner should address the Veteran's lay statements with respect to the reported back injury while lifting a bomb, his NSAID treatment, and his symptomatology. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. d) Is it at least as likely as not (50 percent probability or greater) that the right lower extremity radiculopathy and/or right thigh meralgia paresthetica were caused or aggravated (permanently worsened in severity) by his active service or by a back disability? A rationale should be given for all opinions and conclusions rendered. The opinions should address the particulars of this Veteran's medical history and the relevant medical science as applicable to this claim. If an opinion cannot be rendered without resorting to speculation, the examiner should state whether the inability to provide an opinion was due to a need for further information (with said needed information identified) or because the limits of medical knowledge had been exhausted regarding the etiology of the disorder. If the December 2011 examiner is not available, obtain the requested opinion from another medical professional. If the examiner determines that an additional examination of the Veteran is necessary to provide a reliable opinion as to causation and aggravation, such examination should be scheduled. However, the Veteran should not be required to report for another examination as a matter of course, if it is not found to be necessary. The claims folder must be made available to and reviewed by the examiner. 3. Then, the RO should review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. In this regard, the RO should ensure that the detailed question asked by the Board has been addressed by the examiner. If any development is incomplete, appropriate corrective action is to be implemented. Specific attention is directed to the addendum medical opinion. If the requested addendum does not include adequate responses to the specific opinions requested, it must be returned for corrective action. 38 C.F.R. § 4.2 (2012); see also Stegall v. West, 11 Vet. App. 268 (1998). 4. When the development requested has been completed, and the RO has ensured compliance with the requested actions, this case should again be reviewed by the RO on the basis of the additional evidence. If the benefits sought are not granted, the appellant and his representative, if any, should be furnished a Supplemental Statement of the Case, and be afforded a reasonable opportunity to respond before the record is returned to the Board 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). 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). ______________________________________________ K.J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs