Citation Nr: 1309114 Decision Date: 03/18/13 Archive Date: 03/25/13 DOCKET NO. 07-31 842 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a disorder of the thyroid gland, to include as manifested by hypothyroidism, to include as secondary to service-connected diabetes mellitus. 2. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus and/or liver disease. 3. Entitlement to service connection for an eye disorder, to include cataracts, to include as secondary to service-connected diabetes mellitus. 4. Entitlement to an initial rating in excess of 20 percent for service-connected diabetes mellitus. 5. Entitlement to an initial rating in excess of 10 percent for diabetic neuropathy of the right lower extremity prior to September 28, 2012, and in excess of 20 percent thereafter. 6. Entitlement to an initial rating in excess of 10 percent for diabetic neuropathy of the left lower extremity prior to September 28, 2012, and in excess of 20 percent thereafter. 7. Entitlement to an evaluation in excess of 10 percent for bilateral hearing loss. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. M. Donahue, Associate Counsel INTRODUCTION This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). 38 U.S.C.A. § 7107(a)(2) (West 2002). The Veteran had active service in the United States Air Force from March 1955 to September 1976. This matter comes before the Board of Veterans' Appeals (Board) from January 2007 and April 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The January 2007 decision granted service connection for diabetes mellitus, rated 20 percent disabling, and right and left lower extremity peripheral neuropathy, rated 10 percent disabling each. Service connection was denied for hypertension, hypothyroidism, retinopathy, and liver cirrhosis with portal hypertension. This decision also denied service connection for bilateral hearing loss and tinnitus; later decisions during the processing of the appeals granted entitlement to these benefits. The April 2010 decision granted an increased 10 percent evaluation for bilateral hearing loss, effective from January 8, 2010. This is a separate claim for increased evaluation, and does not relate to the initial grant of service connection. The Veteran appeared at a May 2011 personal hearing held before the undersigned at the RO. At his request, testimony was limited to the issues of evaluation of hearing loss and service connection for a liver disorder, though all issues remained on appeal. A transcript is of record. The appeal was previously before the Board in January 2012, when the appellate matters were remanded to the RO via the Appeals Management Center (AMC), in Washington, DC for further development. During the processing of that appeal, the AMC issued a December 2012 rating decision granting service connection for liver disease; this was a full grant of the benefit sought on appeal, and no further question remains before the Board with respect to that issue. The December 2012 decision also granted entitlement to 20 percent evaluations for left and right lower extremity neuropathies, effective from September 28, 2012. As the increased evaluations did not represent the maximum possible rating, and the Veteran has not expressed his satisfaction with the assigned evaluations, the question of proper evaluation of the peripheral neuropathies before and after September 2012 remain on appeal. AB v. Brown, 6 Vet. App. 35 (1993). The case is now returned to the Board for further appellate consideration. The issues remaining on appeal are as characterized above. The Board has not only reviewed the Veteran's physical claims file but also the electronic records maintained in the Virtual VA system to ensure review of the totality of the evidence. A claim for increased evaluation includes a claim for a finding of total disability based on individual unemployability (TDIU) where there are allegations of worsening disability and related unemployability. Rice v. Shinseki, 22 Vet. App. 447 (2009). Here, while the Veteran is not working, he attributes such to retirement and has not alleged unemployability due to service-connected disabilities. The issues of entitlement to service connection for a thyroid gland disorder, an eye disorder, and hypertension, as well as entitlement to an increased rating for hearing loss, are addressed in the REMAND portion of the decision below and are REMANDED. FINDINGS OF FACT 1. Diabetes mellitus has been controlled with insulin and a restricted diet; there is no evidence of any need for regulation of activities. 2. Prior to September 28, 2012, left lower extremity neuropathy is manifested by no worse than mild impairment, demonstrated by subjective complaints of intermittent pain, numbness, cramping at night, and cold sensitivity. 3. Since September 28, 2012, left lower extremity neuropathy is manifested by no worse than moderate impairment, demonstrated by subjective complaints of constant dull pain, numbness, cramping at night, and cold sensitivity. 4. Prior to September 28, 2012, right lower extremity neuropathy is manifested by no worse than mild impairment, demonstrated by subjective complaints of intermittent dull pain, numbness, cramping at night, and cold sensitivity. 5. Since September 28, 2012, right lower extremity neuropathy is manifested by no worse than moderate impairment, demonstrated by subjective complaints of constant dull pain, numbness, cramping at night, and cold sensitivity. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§3.321, 4.1, 4.3, 4.7, 4.119, Diagnostic Code 7913 (2012). 2. Prior to September 28, 2012, the criteria for an initial disability rating in excess of 10 percent evaluation for left lower extremity neuropathy have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.124, 4.124a, Diagnostic Code 8520 (2012). 3. Since September 28, 2012, the criteria for an initial evaluation in excess of 20 percent for left lower extremity neuropathy have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.124, 4.124a, Diagnostic Code 8520 (2012). 4. Prior to September 28, 2012, the criteria for a disability rating in excess of 10 percent evaluation for right lower extremity neuropathy have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.124, 4.124a, Diagnostic Code 8520 (2012). 5. Since September 28, 2012, the criteria for an initial evaluation in excess of 20 percent for right lower extremity neuropathy have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.124, 4.124a, Diagnostic Code 8520 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). VA's Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). This appeal arises from the Veteran's disagreement with the initial evaluations assigned following the grants of service connection in the January 2007 rating decision. Once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). No additional discussion of the duty to notify is therefore required. VA also has a duty to assist the Veteran in the development of the claim, which is not abrogated by the granting of service connection. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. VA has done everything reasonably possible to assist the Veteran with respect to his claims in accordance with 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c). Service treatment records and post-service VA treatment records have been associated with the claims file. All identified and available private treatment records have been secured. The Veteran has not indicated, and the record does not contain evidence, that he is in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159 (c)(2). The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Repeated VA examinations have been afforded the Veteran to ensure an accurate disability picture is available for review at all stages of the appeal; examiners have made all required findings necessary for application of the rating schedule criteria. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Increased Rating Claims Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 requires that medical reports be interpreted in light of the whole recorded history, and that each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.7 provides that, where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 4.3. An appeal from the initial assignment of a disability rating requires consideration of the entire time period involved, and contemplates 'staged ratings' where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). However, "staged ratings" are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. In Baylor All Saints Health Center treatment records dated from October 2000 to July 2007, the Veteran was treated for non-insulin dependent diabetes starting in March 2001. A November 2000 note reported the Veteran had a history of heavy alcohol intake with enlarged liver. In a May 2001 record, the Veteran denied any pain in his feet. In a February 2005 note, the Veteran complained of parasthesias in his toes. During a March 2006 follow-up, the Veteran denied parasthesias, and in a March 2007 note, the Veteran reported that his toes were doing OK. During an August 2006 VA examination, the Veteran reported he was diagnosed with borderline diabetes back in 1976, and given a diagnosis of diabetes about 10 years ago. He stated he was initially treated with diet and medications, but he switched to insulin two weeks ago. He denied any history of ketoacidosis or hypoglycemic spells. He has never been hospitalized for his diabetes. He is on a restricted diet, but does not restrict his activities due to his diabetes. He sees his diabetes doctor every two months. The Veteran reported some numbness and tingling in his toes, primarily his big toe for the past two years. He reported it is very mild. He requires no medication for it and it does not limit his activities. It primarily bothers him at night when the sheets are not on his feet. Upon physical examination, the examiner found slight decreased sensory vibratory sensation in his big toes, but for the most part soft touch, pinprick, and proprioception were intact. The diagnoses were diabetes, well controlled, and very mild peripheral neuropathy. During a January 2008 VA examination, the Veteran reported numbness and tingling mainly in the tips of this toes, excessive cold sensitivity, and that he needs to wear a heated blanked even during the summer. The Veteran complained of cramps in his bilateral lower extremities, but reported it does not bother him to walk. He reported he is able to mow his yard with a self-propelled lawnmower. He denied any motor weakness in his bilateral lower extremities. Upon physical examination, the examiner noted decreased sensation to light touch and vibration in the bilateral toes. The diagnosis was mild peripheral neuropathy of his bilateral lower extremities. During a VA examination dated September 2012, the Veteran's diabetes mellitus was noted as controlled with restricted diet and prescribed insulin more than 1 injection a day. There was no restriction of activities, and no record of episodes of ketoacidosis requiring hospitalization over the past 12 months. Also during the September 2012 VA examination, the Veteran complained of mild constant pain, and moderate intermediate pain, paresthesias, numbness, and cramping at night. Physical examination showed moderate incomplete paralysis, intermittent pain, paresthesias and/or dysesthesias, and numbness. The Veteran was also shown to have good muscle strength of the right and left lower extremities and normal deep tendon reflexes. The examination also showed trophic changes. The examiner noted that he Veteran's lower extremity peripheral neuropathy is mild to moderate in severity and does not inhibit the Veteran from obtaining and maintaining gainful employment. In an October 2012 private treatment report, the Veteran reported he has burning in both feet, worse when standing or at night when the sheets touch his feet. He denied numbness, tingling, and burning pain elsewhere. He does not have significant weakness or falls. Upon examination, the examiner noted sensation was intact to light touch, temperature, and pinprick bilaterally. His symmetric sensory loss presented in a stocking-glove distribution to level of 2/4, symmetric throughout except absent at ankles bilaterally with down-going toes. The examiner reported an impression of diabetic neuropathy, worsening recently. In multiple statements, the Veteran has complained of shooting and burning pain in his feet, and that he needs to sleep with a heating blanket both summer and winter to keep his legs from cramping. He is taking medication. Diabetes After careful review, the Board finds that the evidence does not support the assignment of an initial rating in excess of 20 percent for the Veteran's diabetes mellitus disability. In this case, the objective medical evidence shows that the Veteran's diabetes mellitus requires insulin and some restrictions in his diet. Under Diagnostic Code 7913 the Veteran is entitled to a 20 percent disability rating for treatment with insulin or an oral hypoglycemic agent and a restricted diet. To be entitled to a higher, 40 percent disability rating the Veteran must be treated with insulin as well as have restrictions on diet and regulation of his activities. 38 C.F.R. § 4.119, Code 7913. "Regulation of activities" for purposes of evaluation of diabetes refers to the need to monitor, restrict, or modify activity, particularly strenuous activity, in order to maintain blood sugar control. Appropriate findings would relate to the need to monitor blood sugar before, during, or after activity; to eat sugary foods; to take additional medication; or directives to not engage in strenuous activity due to blood sugar levels. No treating doctor or examiner has noted any need to restrict or regulate activity for purposes of blood sugar control. The Veteran has alleged such is necessary, but as a layperson, the Veteran is not competent to render a medical opinion relating activity to blood sugar. He is able to report when he is fatigued or nauseous, and what his blood sugar levels might be, but he cannot prescribe for himself a plan of diabetic care. Accordingly, no evaluation in excess of 20 percent is warranted. The rating criteria for diabetes are successive. "Successive" rating criteria is where the evaluation for each higher disability rating includes the criteria of each lower disability rating, such that if a component is not met at any one level, the Veteran can only be rated at the level that does not require the missing component. Tatum v. Shinseki, 23 Vet. App. 152, 156 (2008). The lack of a need for regulation of activity is fatal to any claim for evaluation in excess of the current 20 percent. Peripheral Neuropathy As the analysis of the right and left lower extremities is substantially the same, the limbs are discussed together here. Prior to September 28, 2012 Prior to September 28, 2012, the disability picture presented reflects the criteria for 10 percent ratings for peripheral neuropathy of the left and right lower extremities. The medical evidence of record shows that the Veteran's peripheral neuropathy is manifested by subjective complaints of pain, cramping at night, and intermittent loss of sensation of the left lower extremities. Decreased sensation was tested. The medical evidence also shows that the Veteran's left and right legs have normal motor strength, and that his gait was normal, and that he is able to mow his yard with a self-propelled lawnmower. The examiner described the neuropathy as a mild disorder. In light of the foregoing, and in the absence of such symptoms as decreased muscle strength, abnormal ambulation, or other impairment of his left or right lower extremity, the impairment cannot be considered greater than mild in nature. Therefore, disability ratings for peripheral neuropathy of the left and right lower extremities in excess of 10 percent rating prior to September 28, 2012, are not warranted. See 38 C.F.R. Part 4, §4.123, 4.124, 4.124a, Diagnostic Code 8520. Since September 28, 2012 The evidence of record indicates a worsening of the Veteran's diabetic peripheral neuropathy of the lower extremities beginning September 28, 2012; prior to that date there is no evidence documenting symptoms warranting an increased evaluation. The disability picture presented after that date most accurately reflects the criteria for 20 percent ratings for peripheral neuropathy of the left and right lower extremities. At the September 28, 2012 VA examination, the Veteran complained of multiple moderately severe symptoms and, upon physical examination, the examiner specifically noted findings of moderate right and left lower extremity peripheral neuropathy. The Veteran complained of constant mild pain with occasional intermittent increases. He reported numbness, and some areas of decreased light touch sensation were noted in the toes. Further, trophic changes, marked by loss of hair around the feet and ankles, and nail discoloration and disfigurement were observed. However, the Veteran was also shown to have good muscle strength of the right and left lower extremities and normal deep tendon reflexes. The examiner characterized the condition as mild to moderate. This is supported by the October 2012 private evaluation, which noted worsening burning pain; medications were increased at that time. In the absence of such neurologic symptoms of the left or right foot or leg such as deceased muscle strength or other impairment his lower extremities, his neuropathy of the right and left lower extremities cannot be considered greater than moderate in nature after September 28, 2012. See 38 C.F.R. Part 4, §4.123, 4.124, 4.124a, Diagnostic Code 8520. Extraschedular Evaluation In exceptional cases where schedular evaluations are found to be inadequate, consideration of an extra-schedular evaluation is made. 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extra-schedular evaluation is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimants exceptional disability picture exhibits other related factors identified in the regulations as 'governing norms.' Id. see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. The record does not establish that the rating criteria are inadequate. All applicable criteria provide for higher evaluations for more severe or additional symptoms which are simply not present here. Further, those criteria fully contemplate the Veteran's complaints and the objective findings. No further discussion of extraschedular evaluation is warranted. ORDER Entitlement to an initial rating in excess of 20 percent for service-connected diabetes mellitus is denied. Entitlement to an initial rating in excess of 10 percent for diabetic neuropathy of the right lower extremity prior to September 28, 2012, and in excess of 20 percent thereafter, is denied. Entitlement to an initial rating in excess of 10 percent for diabetic neuropathy of the left lower extremity prior to September 28, 2012, and in excess of 20 percent thereafter, is denied. REMAND In January 2012, the Board directed that medical opinions be sought with regard to any potential relationship between the Veteran's claimed hypertension, thyroid disorder, and eye disabilities and active service. Additionally, examination for update findings with regard to hearing loss were needed. With regard to hypertension, the September 2012 VA reviewer opined that it was less likely than not proximal to, aggravated, or caused by diabetic nephropathy. Renal problems were minor, and even during a period of acute renal failure, hypertension was not impacted. The examiner further found that hypertension was less likely than not aggravated by a liver disease to include carcinoma and cirrhosis. The examiner did not, however, give an opinion as to whether the Veteran's hypertension was caused by liver disease. He also failed to provide the required rationale with respect to aggravation by a liver disorder. Therefore, the Board finds the opinion is inadequate for rating purposes and another VA opinion must be obtained. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Regarding a thyroid disability, the Board had directed that an examiner opine as to any relationship between diabetes and a thyroid condition. The September 2012 examiner did discuss studies and medical findings of some correlation between diabetes and thyroid problems, indicating some possibility of a causal or aggravating connection. He also described the impact alcohol could have on thyroid function. The examiner did not distinguish between the seriousness of the two risk factors he cited; he merely reported them. While he did render a negative opinion, the absence of a rationale for determining alcohol use was the causal factor renders the opinion inadequate. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Remand is required for an explanation. With regard to the issue of service connection for an eye disorder, the Board notes that January 2012 remand indicated an eye examination was required to determine whether the Veteran has cataracts or any other eye disorder related to service or any service-connected disorder to include diabetes. Although the diabetes examiner commented on the presence of eye conditions, he apparently did no current testing, and is not identified as a qualified eye specialist in any case. Therefore, the Board finds the issue must be remanded to obtain an adequate VA opinion as stated in the January 2012 Board remand. With regard to the issue of an increased rating for a hearing loss disorder, the Board notes that January 2012 Board remand specifically requested a VA hearing test. However, there is no indication in the file that a hearing test was afforded the Veteran. It appears the VA hospital noted the claim, and attempted to schedule an appropriate specialist examination, but this was cancelled by the RO for unknown reasons. Updated findings, with commentary as to the validity of testing, is still required, and hence remand is necessary. Accordingly, the case is REMANDED for the following action: (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. Associate with the claims file any outstanding complete treatment records identified by Veteran or in the record. All efforts must be documented in the record, and must include specific requests to search and/or recall any archived or otherwise stored records. 2. Schedule the Veteran for a VA Hypertension examination. The complete claims file must be reviewed in conjunction with the examination. The examiner must opine as to whether it is at least as likely as not hypertension was caused or aggravated by service-connected liver disease. A full and complete rationale for any opinion expressed is required. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). Jones v. Shinseki, 23 Vet. App. 382 (2010). 3. Schedule the Veteran for a VA Thyroid and Parathyroid examination. The complete claims file must be reviewed in conjunction with the examination. The examiner must opine as to whether it is at least as likely as not any current thyroid disability or dysfunction was caused or aggravated by service-connected diabetes. The examiner must discuss the September 2012 examination and the identification of diabetes and alcohol as risk factors. A full and complete rationale for any opinion expressed is required. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). Jones v. Shinseki, 23 Vet. App. 382 (2010). 4. Schedule the Veteran for a VA eye examination. The complete claims file must be reviewed in conjunction with the examination. The examiner must identify all current eye conditions, and must opine as to whether it is at least as likely as not any such was caused or aggravated by service-connected diabetes. Retinopathy and cataracts must be specifically discussed. A full and complete rationale for any opinion expressed is required. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). Jones v. Shinseki, 23 Vet. App. 382 (2010). 5. Schedule the Veteran for a VA audio examination. The examiner must perform all required testing, and should describe current manifestations of hearing loss, as well as the impact of the disability on the Veteran's daily functioning. 6. Review the claims file to ensure that all of the foregoing requested development is completed, and arrange for any additional development indicated. Then readjudicate the claims on appeal. If any of the benefits sought remain denied, issue an appropriate supplemental statement of the case and provide the Veteran and his representative the requisite period of time to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. 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. 2011). ______________________________________________ WILLIAM H. DONNELLY Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs