Citation Nr: 1311883 Decision Date: 04/10/13 Archive Date: 04/19/13 DOCKET NO. 09-28 218 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to service connection for a respiratory disability, to include bronchitis, asthma, emphysema, and chronic obstructive pulmonary disease (COPD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A.J. Turnipseed, Counsel INTRODUCTION The Veteran served on active duty from June 1967 to June 1970. This matter comes before the Board of Veterans' Appeals (Board) from a June 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah. In October 2009, the Veteran testified before the undersigned Veterans Law Judge at a Travel Board hearing. A transcript of the hearing is associated with the record. In January 2010, the Board issued a decision wherein the claim of service connection for bronchitis was reopened (as it had been previously denied in a March 1987 rating decision) and the issues of entitlement to service connection for hypertension, COPD, and bronchitis were remanded for additional development. The appeal has been returned to the Board for adjudication. As reflected on the title page of this decision, the issues of service connection for bronchitis and COPD have been recharacterized as entitlement to service connection for a respiratory disability, to include bronchitis, asthma, emphysema and COPD. In this regard, while the Veteran filed separate claims specifically seeking service connection for bronchitis, the record reflects that the Veteran has been variously diagnosed with several respiratory disabilities during the appeal period. Such is reflected in the characterization of the issue listed on the title page of this decision. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the Court of Appeals for Veterans Claims (Court) found that the scope of a claimant's claim includes any disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). For the reasons expressed below, the issue of entitlement to service connection for a respiratory disorder is, again, being remanded to the RO, via the AMC. VA will notify the Veteran when further action, on his part, is required. FINDINGS OF FACT 1. The Veteran served in-country in Vietnam and was exposed to Agent Orange. 2. The Veteran's hypertension is in no way directly or presumptively related to active military service and continuity of symptomatology since service has not been demonstrated. CONCLUSION OF LAW Hypertension was not incurred in or aggravated by active service and may not be presumed to have been incurred as a result of service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1137 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the Court held that the VCAA 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. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on the claim for VA benefits. In the instant case, VA has satisfied its duty to notify the Veteran under the VCAA. Specifically, April 2009 and March 2009 letters, sent prior to the initial unfavorable AOJ decision issued in June 2009, advised the Veteran of the evidence and information necessary to substantiate his service connection claims, as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, the letters informed the Veteran of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. As such, the Board finds that the Veteran has been provided all required notice. Relevant to the duty to assist, the Veteran's service treatment records, as well as all post-service treatment records identified by the Veteran and the record have been obtained and considered. The Veteran has not identified any additional, outstanding records that he wishes to be considered in his appeal. The Board notes that the Veteran also has a Virtual VA paperless claims file, which is a highly secured electronic repository that is used to store and review documents involved in the claims process. The Board has reviewed the contents of the paperless file, and it is apparent that the RO reviewed all evidence in the paperless claims file as well. In relevant part, as noted in the introduction, in January 2010, the Board remanded the issue of entitlement to service connection for hypertension for additional development. All requested development was conducted. Additional treatment reports were received and the Veteran underwent another VA examination. Thus, the mandates of the remand were substantially complied with. Of note, the Veteran was afforded a VA examination in March 2010 in conjunction with his claimed hypertension. There is no allegation or indication that the examination or opinion rendered in this appeal was inadequate. In any event, the examiner reviewed the Veteran's claims file and clinical findings, and rendered a medical opinion based on medical expertise. The Veteran was also given an opportunity to set forth his contentions at the hearing before the undersigned in October 2009. At Board hearings, a Veterans Law Judge has a duty to explain fully the issues and a duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). The record reflects that at the Board hearing, the undersigned set forth the issues to be discussed and sought to identify any further development that was required to help substantiate the Veteran's claims. The Veteran presented testimony regarding why he felt service connection was warranted for his disabilities and knew or should have known that he could submit any records that he thought were relevant to his claim. Finally, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. Appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Based on the foregoing, it is the Board's conclusion that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of the claim on appeal. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Depending on the evidence and contentions of record in a particular case, lay evidence can be competent and sufficient to establish a diagnosis and medical etiology of a condition. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009), Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. With respect to continuity of symptomatology, the Court recently held that, under 38 C.F.R. § 3.303(b), the theory of continuity of symptomatology is an alternative route to establish service connection for specific chronic diseases and can only be used in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Hypertension is specifically listed. Additionally, service connection for hypertension will be rebuttably presumed to have been incurred in or aggravated by service if manifested to a compensable degree within one year following the Veteran's date of discharge from active service. 38 U.S.C.A. § 1110, 1137; 38 C.F.R. §§ 3.307, 3.309. Note (1) of 38 C.F.R. § 4.104, Diagnostic Code 7101 states that hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. For purposes of this section, the term hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 91) (2012). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Hypertension The Veteran has asserted that service connection is warranted because his current diagnosis of hypertension is related to the elevated blood pressure readings he had during and after service. He has asserted that he believes his elevated blood pressure readings were manifested as a result of the medication he was given during service. After carefully reviewing the lay and medical evidence of record, the Board finds that the preponderance of the evidence is against the grant of service connection for hypertension. While the Veteran's April 1970 separation examination report shows that his blood pressure reading was 120/84, which might be considered an elevated blood pressure reading, the Board finds probative that the elevated reading was not accompanied by an actual diagnosis of hypertension, or further follow up for additional blood pressure readings. Additionally, there are no additional elevated blood pressure readings during service. Despite the Veteran's assertions, the STRs do not show that the Veteran manifested chronically elevated blood pressure readings during service, including after taking medication prescribed for him. Additionally, the Board notes that neither elevated blood pressure readings nor a diagnosis of hypertension is shown by the evidence of record during the Veteran's first post-service year or for many years thereafter. To the contrary, in July 1970, February 1976, and September 1976, the Veteran's blood pressure was within normal limits at 148/76, 140/80 and 120/70, respectively. In 1985, a blood pressure reading of 150/84 was noted. In June 1986, "15/102" with an impression of normal male with questionable hypertension was noted. Elevated blood pressure readings are also shown in post-service medical records dated from 1992 to 2001; however, the first actual diagnosis of hypertension reflected in the record was rendered in March 2000 and confirmed on VA examination in March 2010. There is a current diagnosis of hypertension and a possible elevated blood pressure reading was noted on discharge examination. Nonetheless, the probative and persuasive evidence does not attribute the Veteran's current hypertension to his military service or show that it manifested to a compensable degree within a year after service. In evaluating this claim, the Board finds probative that the Veteran was not diagnosed with hypertension during service and that chronically elevated blood pressure readings are not shown during service. There is one elevated blood pressure reading at separation from service; however, the Board finds probative that this was an isolated occurrence of an elevated blood pressure reading and that the reading was not accompanied by a diagnosis of hypertension. In fact, subsequent blood pressure readings conducted in 1970 and 1976 were within normal limits. In this regard, the Board finds probative that the first post-service elevated blood pressure readings were in 1985 and 1986, more than 15 years after the Veteran's discharge from service, and even at that time in 1986, questionable hypertension was noted. Again, the first actual diagnosis of hypertension in the record is shown in March 2000, approximately 30 years after discharge from service. The Veteran's assertions of continuity of symptomatology since service are acknowledged. The Veteran testified that he was first diagnosed with hypertension in 1979 but that he had elevated blood pressure readings prior to that time. The Veteran is competent to assert that he experienced elevated blood pressure readings in service and has had symptoms since service. However, the Veteran's statements are not credible, as they are outweigh by other contemporaneous objective evidence of record. While the Board has been unable to obtain medical records of his initial diagnosis, as the physician who treated him at the time is deceased, affirmative evidence records a diagnosis of hypertension many years post service. Even when assuming that the report of being diagnosed with hypertension in 1979 is considered competent, the Board notes that the statements still fail to establish service incurrence of hypertension or continuity of symptomatology following service. At best, the Veteran's statements establish that he had no continuous elevated blood pressure readings after service and still was not diagnosed with hypertension until 1979. The lack of credible evidence for nine years in the evidentiary record is a factor for consideration against the finding that the elevated blood pressure reading shown at separation from service was indicative of or caused a chronic disorder. See 38 C.F.R. § 3.303(b). Again, blood pressure readings from 1970 through 1976 were affirmatively normal. In this context, the Board also finds it probative that the Veteran sought to establish service connection for other disabilities a few years after discharge from service, in 1971 and 1976, whereas a claim seeking service connection for hypertension was not referenced. This evidence is probative because it shows the Veteran was aware he could seek VA benefits for disabilities he believed were incurred in or related to service or had been chronic since that time. However, when he filed his claims in 1971 and 1976, the Veteran did not mention that he had been experiencing elevated blood pressure readings since service or that he had been diagnosed with hypertension since service. The Veteran's assertions of experiencing continuity of symptomatology since service are inconsistent with other, affirmative independent evidence of record, and therefore, his assertions are not credible and hence, are of no probative value. In addition to the lack of probative and persuasive evidence establishing service incurrence or continuity of symptomatology after service, there is no competent, credible, and probative evidence of record that establishes a medical nexus between the Veteran's military service and hypertension. In April 2009, Dr. D.H. stated that after reviewing the Veteran's service medical records, he believes it is as likely as not that the Veteran's hypertension problems began while in the military. While Dr. D.H.'s statement is considered competent medical evidence, his statement is afforded no probative value because it is not supported by a rationale. Indeed, while Dr. D.H. stated that he reviewed the Veteran's service treatment records, he did not identify what evidence supports his conclusion, particularly given the affirmative evidence showing no diagnosis of hypertension during service or chronically elevated blood pressure readings during service, as well as the affirmative evidence showing normal findings after service. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (a medical opinion that contains only data and conclusions is accorded no weight). There is no other medical evidence or opinion of record that attributes the Veteran's hypertension to military service. In fact, the Veteran was afforded a VA examination in March 2010 to determine if his current hypertension is related to service. The March 2010 VA physician reviewed the claims file and conducted a physical examination, after which he rendered a diagnosis of hypertension. However, the VA physician stated that, medically speaking, one cannot state whether the Veteran's hypertension is related to military service. Rather, the physician stated that it would be more correct and appropriate to state that hypertension was either diagnosed or not diagnosed in service. The VA physician noted that the Veteran's two in-service blood pressure readings are not diagnostic of hypertension and, as such, stated that the current hypertension is not at least as likely as not related to or caused by his blood pressure readings, which were normal, in service. In making this determination, the March 2010 VA physician further noted that the earliest elevation was a onetime event shortly after leaving service and there is no indication of elevation until several years afterwards. The physician also noted that the Veteran did not start treatment for hypertension until almost nine years later. The Board considers the March 2010 VA examination and opinion to be competent, credible, and probative evidence with respect to whether the Veteran's current hypertension is related to his military service. The Board finds that the March 2010 VA examination is adequate for adjudicative purposes, as the physician reviewed the claims file, interviewed the Veteran, and conducted a physical examination. There is also no indication or allegation that the VA physician was not fully aware of all relevant facts in this case. In fact, the VA physician provided an opinion that was based upon the evidence of record and supported by a complete rationale. Moreover, the VA physician's opinion is supported by the other evidence of record, inclusive of the service and post-service medical evidence, which does not show a diagnosis of hypertension or chronically elevated blood pressure readings during service or for many years thereafter. Also, the Board has considered the Veteran's lay assertions of a nexus between his hypertension and medication taken during service. In this regard, the Board notes that the Veteran is competent to report having elevated blood pressure readings, as he is capable of taking his own blood pressure and observing his blood pressure while it is being taken. See Layno, supra. However, hypertension is not a disease that is generally capable of lay observation and report, as it is generally observed and diagnosed in a clinical setting by a medical professional. See, e.g., 38 U.S.C.A. § 4.104, Diagnostic Code 7101, Note (1). As a result, the determination as to the presence and etiology of that disability is a complex medical question. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The question of the relationship between the Veteran's hypertension and medication prescribed while in service is not a simple medical question. That is, it is not argued or shown that the Veteran is otherwise qualified through specialized education, training, or experience to offer an opinion on the relationship between his current disease and any side effects from medication prescribed to him in service. In this case, the Veteran has only offered conclusory statements regarding the relationship between his military service and hypertension, whereas the March 2010 VA physician took into consideration a review of the claims file, a clinical evaluation of the Veteran, and the examiner's medical expertise. As such, the Veteran's statements regarding a nexus between his hypertension and prescribed medication are outweighed by other objective medical evidence of record. The Board has considered whether service connection may be granted for hypertension on a presumptive basis, as a chronic disease. However, the evidence does not show, nor does the Veteran allege, that he manifested symptoms of or was hypertensive within his first post-service year. As noted, there is no evidence of chronic or continuous elevated blood pressure readings during the first post-service year and the evidence of record establishes that the Veteran was diagnosed with hypertension no earlier than 1979, nine years after he was discharged from service. Presumptive service connection for hypertension as a chronic disease is not warranted in this case. See 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309(a). The competent, credible, and probative evidence of record weighs against the grant of service connection for hypertension. Because the evidence preponderates against the Veteran's claim, the benefit-of-the-doubt doctrine is not for application. See Gilbert, supra. ORDER Entitlement to service connection for hypertension is denied. REMAND The Veteran is seeking entitlement to service connection for a respiratory disability, which has been variously identified as bronchitis, asthma, emphysema and chronic obstructive pulmonary disease (COPD). See statements from Dr. D.H. dated April 2009 and December 2012; see also October 2012 VHA opinion. The Veteran has asserted that he believes his COPD is related to his exposure to herbicides during service and he also previously asserted that he had trouble breathing during service as a result of his military duties which required that he burn human waste. See May 2009 VA Form 21-4138; see also March 1989 DRO hearing transcript, p.3. The Veteran is presumed to have been exposed to herbicides during service, as service treatment records show that he served in Vietnam and received medical treatment at the Vinh Long Airfield Dispensary from February to August 1969. In support of his claim, the Veteran submitted a written statement from his physician, Dr. D.H. Dr. D.H. stated that, in reviewing the Veteran's service medical records, he believes it is as likely as not that the Veteran's bronchitis and COPD problems began while in the military. See April 2009 statement from Dr. D.H. No supporting rationale was provided, however. Thus, the opinion is inadequate for adjudicative purposes. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (a medical opinion that contains only data and conclusions is accorded no weight). The Veteran received a VA examination in March 2010. The VA physician noted the Veteran's medical history, his current symptoms, and his history of smoking half a pack per day from 1967 to 1974 and 1986 to 1993 and a pack per day from 2000 to 2009. After examining the Veteran, the VA physician stated that there were no clinical signs or symptoms of COPD but he noted that the Veteran uses inhalers, which is consistent with a diagnosis of COPD. The physician also noted the Veteran's smoking history, which he stated was more consistent with the development of COPD versus any chronic bronchitis or allergic rhinitis. Pulmonary function tests (PFTs) were subsequently performed with the use of a bronchodilator and were interpreted as showing normal spirometry, lung volumes, and diffusing capacity. The March 2010 VA physician stated that the findings validated his previous conclusions. In August 2010, the Veteran submitted PFTs conducted by his private physician in March 2010, which reflect that he had moderate airway obstruction. Because of the conflicting diagnoses of record, the Board requested that a medical opinion be obtained from an independent VA physician with respect to the Veteran's current diagnosis and whether any such current respiratory disability is related to his military service. In October 2012, a VA physician who specializes in pulmonary care reviewed the record and provided an opinion. The physician noted that the Veteran was exposed to herbicides during service and, in June 1968, was treated for complaints of chest pain, eye irritation and sinus congestion, although there was no mention of exposure to an irritant prior to that evaluation. Nevertheless, the physician noted that he could not determine if lung restriction is present since lung volumes had not been measured and total lung capacity is needed to make the determination. The physician also stated that PFTs conducted in March 2010 were not reliable because they do not meet acceptability and reproducibility standards. He added that PFTs conducted by VA were normal, but that they showed significant improvement of FEV1, which he stated suggests reversible airflow obstruction, i.e., asthma. In this regard, the physician stated that it is possible the Veteran has asthma. He also noted that some literature suggests that exposure to Agent Orange is associated with an increased incidence of respiratory symptoms, although there is no data that convincingly shows that Agent Orange causes asthma. Nevertheless, the VA physician stated that he believes the Veteran may have developed asthma as a result of his military service. In an addendum report dated December 2012, the same VA physician stated that the available data does not allow him to provide anything more than a speculative opinion. In this regard, the physician stated that, while asthma is suggested by the improvement in FEV1 on the PFTs after inhalation of a bronchodilator, this is not absolute as some people without asthma can show the same response. However, he further noted that, in this case, asthma is a clinical diagnosis with the presence of shortness of breath, chest tightness, and wheezing, but that there is no indication of wheezing or coughing in the few times a lung examination was documented in the record. The VA physician stated that this also does not rule out asthma. In addition to the unclear nature of whether the Veteran has asthma, the VA physician stated that he can definitively state the Veteran does not have COPD, although he could not comment on lung restriction because the measurement of total lung capacity had not been made. In December 2012, Dr. D.H. submitted another statement noting that the Veteran is being treated for COPD, which was established on spirometry and confirmed by a CT scan of the chest. The PFT report and chest CT, which showed severe airway obstruction and emphysema, respectively. The March 2009 PFT report was an unconfirmed report, however. See March 2009 PFT report and March 2012 CT scan of the chest. The record shows that the Veteran has a respiratory disorder, but it is unclear what type of respiratory disorder the Veteran has, e.g., asthma, bronchitis, emphysema and/or COPD. Regrettably, given the uncertainty of which disorder is present and the wavering medical opinions of record, additional development is needed. Accordingly, to ensure that VA has met its duty to assist in developing the facts pertinent to the claim on appeal and to afford full procedural due process, the case is REMANDED for the following: 1. Contact the Veteran to obtain the names and addresses of all VA, private, or other government health care providers and treatment centers where he received any treatment for any respiratory disorder from 2009 until the present. After securing the necessary release(s), obtain those records that have not been previously secured, to include the complete records from all pertinent consultations, testing and imaging. To the extent there is an attempt to obtain any of these records that is unsuccessful, the claims file should contain documentation of the attempts made. Inform the Veteran and his representative of the negative results and provide them with an opportunity to secure the records. 2. After completing any additional notification and/or development action deemed warranted by the record, schedule an examination by a pulmonologist (due to the complexities of the medical questions in the case) in order to evaluate the etiology of the Veteran's current respiratory condition(s), if any. The pulmonologist is requested to review the claims file, examine the Veteran and conduct any test deemed appropriate to include PFTs and CT scans, and provide a written opinion as to the etiology and onset of any respiratory pathology. (The pulmonologist is requested to provide an opinion based on record review alone if the Veteran fails to report for the examination). All appropriate testing should be accomplished. The opinion should include a discussion of the effect and significance, if any, of the Veteran's in-service and post-service lung findings, especially the unconfirmed PFT reports, statements from Dr. D.H., and the 2012 VHA medical opinion. Again, the pulmonologist must clearly set forth the Veteran's current respiratory diagnoses, and for any respiratory disorder diagnosed, the pulmonologist must opine whether any diagnosed respiratory disorder is causally or etiologically related to military service, including exposure to herbicides, burning fumes, or some other cause or causes, to include the use of tobacco. 3. After completing any additional notification and/or development action deemed warranted by the record, review the record and readjudicate the issue on appeal. If the benefit sought on appeal remains denied, the Veteran and his representative should be provided a Supplemental Statement of the Case (SSOC). An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action unless otherwise notified. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is hereby notified that it is his responsibility to report for any scheduled examination and to cooperate in the development of the case, and that the consequences of failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). 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). ____________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs