Citation Nr: 1312804 Decision Date: 04/17/13 Archive Date: 05/02/13 DOCKET NO. 07-07 621 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for a skin condition of the hands, feet, buttocks, and groin, to include as secondary to herbicide exposure. 2. Entitlement to service connection for a right knee disability, to include as secondary to a service-connected shell fragment wound (SFW) to the right thigh. 3. Entitlement to service connection for a right hip disability, to include as secondary to a service-connected SFW to the right thigh. 4. Entitlement to service connection for a low back disability, to include as secondary to a service-connected SFW to the right thigh. 5. Entitlement to a disability rating in excess of 70 percent for posttraumatic stress disorder (PTSD). 6. Entitlement to a compensable disability rating for bilateral hearing loss. REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD D. M. Ames, Counsel INTRODUCTION The Veteran had active service from November 1965 to October 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from September 2006 and November 2007 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. The September 2006 rating decision denied service connection for a skin condition, a right knee disability, a right hip disability, a low back disability, and a compensable evaluation for bilateral hearing loss. The November 2007 rating decision denied a disability rating in excess of 50 percent for PTSD. The Veteran testified at a hearing in August 2009 before the undersigned. A copy of the transcript has been associated with the claims file. In August 2011 the Board remanded this case to the RO via the Appeals Management Center (AMC) for further development and it has now been returned to the Board. In an October 2012 rating decision, the RO increased the Veteran's rating for PTSD to 70 percent and granted a total rating based upon individual unemployability (TDIU) due to service-connected disability. Applicable law mandates that when a veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet. App. 35 (1993). A review of the Virtual VA paperless claims processing system reveals additional VA treatment records from November 2010 to May 2012 that are pertinent to the present appeal. In the October 2012 Supplemental Statement of the Case (SSOC), the RO specifically stated that the Veteran's VA treatment records were reviewed through October 2011 prior to the adjudication of the claims. The electronic records from October 2011 to May 2012 reference treatment for the Veteran's claimed knee and back disabilities. However, they do not pertain to whether there is a nexus between the disabilities and his period of service or his service-connected SFW, which are the points of contention in this case. Therefore there is no prejudice to the Veteran in the Board's adjudication of his claims. The issues of entitlement to service connection for a right knee disability, a right hip disability, and a low 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. The evidence of record, to include competent medical evidence and lay evidence, is at least in equipoise as to whether the Veteran has a skin condition that began during active service or is related to an incident of service. 2. The Veteran's PTSD causes occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking, or mood. 3. At its most severe, the Veteran has Level III hearing loss in each ear. CONCLUSIONS OF LAW 1. The Veteran's skin condition was incurred in service. 38 U.S.C.A. §§ 1110, 1154, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 2. The criteria for a disability evaluation in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.125, 4.130, Diagnostic Code 9411 (2012). 3. The criteria for a compensable disability evaluation for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.353, 3.385, 4.1-4.14, 4.85, 4.86, Diagnostic Code 6100 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). With regard to the Veteran's claim for service connection for a skin condition, VA has substantially satisfied its duties to notify and assist in this case. Id. To the extent that there may be any deficiency of notice or assistance, there is no prejudice to the Veteran in proceeding with this appeal given the favorable nature of the Board's decision. See Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92. With regard to his remaining claims, upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim, and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). The notice must be provided to the Veteran prior to the initial adjudication of his claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA has satisfied its duty to notify by issuing pre-adjudication notice letters in July 2006 for the September 2006 rating decision and in August 2007 for the November 2007 rating decision. The July 2006 letter advised the Veteran of what evidence was required to substantiate his service connection claims, and of his and VA's respective duties for obtaining evidence. In a claim for an increased evaluation, the VCAA requirement is generic notice: the type of evidence needed to substantiate the claim, which consists of evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The August 2007 letter advised him that he needed to submit evidence showing that his PTSD had increased in severity. Both letters provided notice regarding the disability evaluation and effective date elements of a service connection claim. Dingess, 19 Vet. App. at 473. The duty to assist provisions of the VCAA have been met. The claims file contains service treatment records (STRs), reports of post-service medical treatment, and reports of VA examinations in August 2006, March 2009, and September 2011. The August 2006 and September 2011 examinations were adequate because they were based on a thorough examination, a description of the Veteran's pertinent medical history, a complete review of the claims folder, and appropriate diagnostic tests. The examiners also provided rationales for their opinions. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding an examination is considered adequate when it is based on consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). He testified at a hearing in August 2009. This case was remanded in August 2011 so that the Veteran could undergo VA examinations, which he did in September 2011. There was substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran has not made the RO or the Board aware of any additional evidence that must be obtained in order to fairly decide the appeal. He has been given ample opportunity to present evidence and argument in support of his claims. Pursuant to 38 C.F.R. § 3.655, all relevant evidence necessary for an equitable disposition of the Veteran's appeal of this issue has been obtained and the case is ready for appellate review. General due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2012). Entitlement to Service Connection for a Skin Condition Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity for certain diseases. 38 C.F.R. §§ 3.303(a),(b), 3.309(a); see also Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013). 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). In order to establish service connection for the claimed disorder, there must be (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, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303; see also Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). As will be discussed below, the Veteran asserts that his right knee, right hip, and low back disabilities were caused by his service-connected SFW injury. A disability which is proximately due to or the result of a service-connected disease or injury shall be service-connected. When service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a non-service-connected disability which is aggravated by a service-connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b) (2010); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). A claim for secondary service connection requires medical evidence that connects the asserted secondary disorder to the service-connected disability. Velez v. West, 11 Vet. App. 148, 158 (1998). In order to establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The provisions of 38 C.F.R. § 3.310 were amended, effective October 10, 2006; however, and the new provisions require that service connection not be awarded on an aggravation basis without establishing a pre-aggravation baseline level of disability and comparing it to current level of disability. 71 Fed. Reg. 52744-47 (Sept. 7, 2006). Although the stated intent of the change was merely to implement the requirements of Allen, 7 Vet. App. at 448, the new provisions amount to substantive changes to the manner in which 38 C.F.R. § 3.310 has been applied by VA in Allen-type cases since 1995. The Veteran's claim was pending prior to the effective date of the amended regulation. Consequently, the Board will apply the older version of 38 C.F.R. § 3.310, which is more favorable to the Veteran because it does not require the establishment of a baseline before an award of service connection may be made. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (finding that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis herein focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (holding that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Veteran has been diagnosed with several skin conditions including xerosis, tinea infections, and palmar and plantar keratodermas. The first element of a service connection claim is satisfied. Hickson, 12 Vet. App. at 253. At his August 2009 hearing, the Veteran testified that while serving in the Republic of Vietnam, he had skin rashes. He stated that he went up to 57 days without bathing and that he "lived in filth." He testified that he woke up wet and went to bed wet. In the case of a veteran who engaged in combat with the enemy, as in this case, satisfactory lay or other evidence will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, condition or hardships of such service, even though there is no official record of such incurrence or aggravation. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d) (2012). The Veteran is competent to discuss an observable symptom such as a rash. Layno v. Brown, 6 Vet. App. 465 (1994). Further, contracting a skin condition while serving in wet conditions in the Republic of Vietnam is consistent with the circumstances of the Veteran's service. His testimony is credible. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d) (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). The second element of a service connection claim is satisfied. Hickson, 12 Vet. App. at 253. The Veteran asserts that his skin condition was caused by exposure to herbicides while he was serving in the Republic of Vietnam. Diseases associated with exposure to certain herbicide agents used in support of military operations in the Republic of Vietnam during the Vietnam era will be considered to have been incurred in service. 38 U.S.C.A. § 1116(a)(1); 38 C.F.R. § 3.307(a)(6). The Veteran's diagnosed skin conditions are not included on the list of conditions associated with exposure to herbicides. 38 U.S.C.A. § 1116(a)(2); 38 C.F.R. § 3.309(e). The Secretary of the Department of Veterans Affairs has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 67 Fed. Reg. 42600-42608 (2002). Therefore, presumptive service connection is not warranted. The Veteran underwent a VA examination in September 2011. He reported a worsening rash over his skin that first began while he was serving in the Republic of Vietnam. He stated that over the years he had numerous flare ups of his skin condition. The examiner noted thickness of skin on the Veteran's hands and feet. The examiner diagnosed the Veteran with xerosis, intertrigo, palmar and plantar keratodermas, and tinea of the hands, feet, and groin. He opined that these conditions were not caused by service. With regard to xerosis, the examiner stated that it was common for people of any age to contract this condition but it was especially prevalent in patients over age 50. The examiner noted that it is believed to be genetic in origin and it was not caused by exposure to herbicides. He opined that intertrigo was common in the general population, but generally more common among the Veteran's age group. He stated it was thought to be genetic as well. He found that palmar and plantar keratodermas were also genetic. He was unaware of any literature that linked them to herbicide exposure. With regard to tinea infections, the examiner concluded that they were not caused by service. Tinea infections were more prevalent in damp environments where large numbers of people are found. Further, there appeared to be a genetic susceptibility to tinea infections of the skin, which decreased the probability that the Veteran's tinea infections were caused by service. Lastly, the examiner concluded that it was less likely that the Veteran's period of active service altered the natural course of his skin problems or predisposed him to subsequent infections. The VA examiner's opinion provides probative evidence against the Veteran's claim. The Veteran's VA and private medical treatment records show that he has received treatment for skin problems since the mid 1980s. Prior to that time, there were no available treatment records. This lack of medical records cannot be used as evidence against his claim. Buchanan v. Nicholson, 451 F.3d 1331, 1336-1337 (Fed. Cir. 2006). His treated skin conditions included those diagnosed at his VA examination: tinea infections on the hands, feet, and groin, and actinic keratoses. In September 2006, Dr. G. J., the Veteran's private physician who had treated the Veteran since the 1980s, stated that he had skin problems since that time. The Veteran reported to Dr. G. J. that he had multiple rashes in service and ignored them while he was in the military. Dr. G. J. noted that the Veteran had chronic skin problems "since that time." He concluded that the Veteran's rashes "certainly" could have been chemically induced. Dr. G. J. did not have access to the Veteran's claims file when he rendered his opinion. However, this does not reduce the probativity of his conclusion. A physician's review of the claims file is not the determinative factor in assigning probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300 (2008). However, a physician should have information regarding relevant case facts. In this case, Dr. G. J. noted that he treated the Veteran since the 1980s and was clearly familiar with the Veteran's medical history with regard to his skin conditions. His opinion is probative evidence in favor of the Veteran's claim. The Veteran submitted lay statements in support of his claim. In August 2009, he testified that he has had skin problems since serving in the Republic of Vietnam. He stated that while in service he had jungle rot and rashes. He stated that they never went away. He saw a private physician after service until his death in 1972. He attempted to obtain his old records from the physician's daughter, but she told him that they were put in storage and then destroyed. The Veteran testified that while serving in the Republic of Vietnam, he would sometimes go 57 days without a bath and he "lived in filth." He said the environment was always wet. In October 2011, C. H., his wife of over 40 years, stated that the Veteran's skin has been "horrible" since his return from the Republic of Vietnam. Also in October 2011, T. B., the Veteran's oldest daughter, stated that for as long as she could recall, the Veteran had skin problems that were treated, but never completely resolved. The Veteran and his family are competent to describe observable symptoms such as a skin condition. Layno v. Brown, 6 Vet. App. 465 (1994). Further, there is nothing in the record to call their credibility into question. In fact, medical records as early as the mid 1980s show that the Veteran has a history of chronic skin problems. Their statements are credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). The Veteran's August 2009 testimony and the October 2011 statements from his wife and daughter are probative evidence in favor of his claim. Where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993); see also Massey v. Brown, 7 Vet. App. 204, 206-207 (1994). The mandate to accord the benefit of the doubt is triggered when the evidence has reached such a stage of balance. The supportive lay evidence combined with Dr. G. J.'s favorable opinion is equal in probative weight to the unfavorable opinion of the September 2011 VA examiner. Because a state of relative equipoise has been reached in this case, the benefit of the doubt rule will therefore be applied. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996); Brown v. Brown , 5 Vet. App. 413, 421 (1993). Service connection for a skin condition is granted. Increased Evaluation Claims Disability ratings are determined by applying the criteria established in VA's Schedule for Rating Disabilities, which is based upon the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.20 (2011). When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Consideration must given to increased evaluations under other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1. Where an increase in an existing disability rating based upon established entitlement to compensation is at issue, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran submitted his claim for an increased evaluation for hearing loss in February 2006 and for PTSD in July 2007. "The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim." Id., at 509. The law as to the evaluation of evidence and the standard of proof in Veterans' claims is reviewed above and will not be repeated here. PTSD The Veteran's PTSD is currently evaluated as 70 percent disabling under Diagnostic Code 9411, PTSD. 38 C.F.R. § 4.130. The diagnostic criteria set forth in The American Psychiatric Association: Diagnostic And Statistical Manual Of Mental Disorders, (4th ed. 1994) (DSM- IV) for mental disorders have been adopted by VA. 38 C.F.R. § 4.125. Under the General Rating Formula for Mental Disorders, a 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. When it is not possible to separate the effects of the service-connected disability from a non-service-connected condition, such signs and symptoms must be attributed to the service-connected disability. 38 C.F.R. § 3.102, Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). Symptoms listed in the General Rating Formula for Mental Disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. Higher scores correspond to better functioning of the individual. GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging between 41 and 50 are assigned when there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). GAF scores ranging between 31 and 40 are assigned when there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family and is unable to work). It is important to note that a GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV at 32). Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). The Veteran underwent a VA examination for his PTSD in September 2007. He reported feeling very angry. He reported periods where he had nightmares every night, and then periods where he went weeks without any. When he had nightmares, he stated that his wife did not want to sleep in the same bed with him because he thrashed around. He had intrusive thoughts of his stressors every day. He was easily startled by loud noises. He did not like crowds and always chose to sit where he could see the door. He waited in the car while his wife shopped. He stated that he and his wife had been married for 40 years but that their relationship was strained. He preferred to spend time alone, caring for his rabbits and dogs. He spent some time with his cousin, who also served in the Republic of Vietnam. Upon examination, the Veteran was casually dressed and groomed. His speech and thought content were within normal limits. His mood was anxious and depressed and his affect was appropriate to his mood. He was not confused. His memory was grossly intact. He was fully oriented. He did not have delusions or hallucinations. His insight and judgment were adequate. He reported occasional suicidal ideation and denied homicidal ideation. The examiner assigned a GAF score of 48, indicating serious symptoms. The examiner concluded that the Veteran's PTSD symptoms were moderate and persistent. His symptoms did not grossly impair his social functioning. There was no evidence that his PTSD precluded employment or his ability to perform his activities of daily living. In September 2011, the Veteran underwent a second VA examination for his PTSD. The examiner noted that the Veteran's only psychiatric disorder was PTSD. He concluded that his PTSD caused occupational and social impairment with deficiencies in most areas. The Veteran reported that he and his wife had been married since they "were kids," but that their relationship was strained. He stated that they lived in separate parts of the house. He spent his days caring for chickens and rabbits on his property. He saw a counselor at a Vet Center every two to three weeks and took several types of medication. He reported that his treatment had fair efficacy. He reported feeling irritable and angry. He had recently threatened a neighbor with a gun for driving a four wheeler in the neighborhood. The police were called. He also reported a recent altercation with a person on VA property. He stated he was very easily provoked. He had recurrent recollections of his stressor. He had problems falling or staying asleep. He stated he had problems concentrating. He described hypervigilance and an exaggerated startle response. The examiner found that he had depressed mood, anxiety, suspiciousness, impaired judgment, disturbances in motivation or mood, difficulty establishing and maintaining social and work relationships, difficulty adapting to stressful circumstances, impaired impulse control, persistent hallucinations and delusions, and a neglect of personal hygiene. The examiner found that he did not have panic attacks weekly or more, near continuous panic or depression such that it impacted his ability to function independently, mild memory loss, impairment of short and long term memory, memory loss for names of close relatives or self, flattened affect, abnormal speech, difficulty understanding complex commands, impaired abstract thinking, gross impairment in thought processes or communication, an inability to establish relationships, obsessional rituals, suicidal ideation, grossly inappropriate behavior, intermittent inability to perform activities of daily living including personal hygiene, or disorientation to time or place. He was not deemed to be a persistent danger to himself or others. The examiner found that the Veteran's PTSD symptoms were severe enough to interfere significantly with his ability to secure or maintain employment. The Veteran's GAF score was 35. In addition to his VA examinations, VA and private treatment records provide information regarding the severity of his PTSD symptoms. At an October 2006 VA treatment session, he complained of flashbacks, nightmares, problems sleeping, isolation, and avoidance of crowds. He felt irritable and stated he had problems controlling his anger. He displayed hypervigilance by repeatedly checking the locks on his property at night. His GAF score was 55. VA treatment records from November 2007 show complaints of intrusive thoughts of his stressors. He denied suicidal ideation, homicidal ideation, and hallucinations. He stated his relationship with two of his daughters was difficult. A January 2008 VA treatment record listed a GAF score of 60. At a May 2008 VA treatment session he complained of poor sleep. He stated that his mood was neither happy nor sad. His affect was restricted. His thought content and processes were within normal limits. He denied suicidal ideation, homicidal ideation, and hallucinations. His GAF score was 50. In July 2008, Dr. J. C., the Veteran's Vet Center counselor, stated that the Veteran experienced intrusive memories, nightmares, and social isolation. Dr. J. C. did not think the Veteran would return to work. His GAF score was 43. At an August 2008 VA treatment session he stated that he felt like he had spiders crawling on his skin. He heard voices and saw Viet Cong. He complained of nightmares. He felt guilty, irritable, anxious, and jumpy. He denied suicidal ideation. His GAF score was 31. In September 2008, he reported that he was sleeping better. He stated that he felt less angry. He had flashbacks. His mood was "not too good," and his affect was restricted. His thought processes were within normal limits. His GAF score was 31. In August 2009, Dr. J. C. wrote to VA on behalf of the Veteran. He stated he had seen the Veteran 68 times. Their focus in counseling was on sleep disturbance, nightmares, intrusive memories, social withdrawal, and isolation. Dr. J. C. stated that these symptoms led to major disruptions in the Veteran's social functioning. He had "severe difficulties" with his wife and adult children. Most of his relationships were "severely impaired." Dr. J. C. felt that the Veteran was not capable of working. In September 2009, Dr. J. C. stated that the Veteran had nightmares every night and intrusive thoughts every day. Despite a good effort from the Veteran, Dr. J. C. did not think there was much improvement in his symptoms because the Veteran had a continued problem with focus, concentration, and attention to detail "regarding his counseling." In June 2011, G. S., the Veteran's Vet Center readjustment counselor, stated that he had treated the Veteran since February 2010. The Veteran's symptoms included re-experiencing his stressor, loss of interest in previously enjoyed activities, feeling cut off from other people, emotional numbness, hypervigilance, and feeling the need to be on guard. His concentration was poor, it was hard for him to stay focused. He could not sustain independent tasks without help. He had severe anxiety that sometimes resulted in panic attacks or feelings of being overwhelmed. He lacked emotional stability, demonstrated by a short fuse and outbursts of anger. The Veteran also submitted lay evidence in support of his claim. He stated that he slept for six hours each night. He reported nightmares. He stated that he was startled by loud noises. He avoided crowds and waited in the car while his wife shopped. He described frequent outbursts of anger, including when he was at work. He stated that he could not handle stress. In October 2011, C. H., his wife, stated that when the Veteran arrived home from the Republic of Vietnam, he was violent, full of rage, and suspicious. Currently, she stated that he checks the yard for security problems on a regular basis. She described him as reclusive. They did no socializing except for attending church once a week. He spent a lot of time watching television in his room. He thrashed around in his sleep when he had nightmares. Also in October 2011, T. B., his daughter, stated that the Veteran could not control his anger. He was suspicious of everyone. He double and triple checked "security areas" in their home. He was unable to sleep until he checked the locks. He isolated himself from everyone except for his immediate family. He was unable to work with other people. He thrashed around in his sleep during nightmares and then could not remember the following morning. The combined evidence of the Veteran's symptoms shows that his PTSD produces occupational and social impairment with deficiencies in most areas. Although some of his symptoms such as hearing voices and seeing Viet Cong fall into the category of hallucinations, the evidence does not show that these are persistent. Although his GAF score was 31 in August and September 2008 and 35 in September 2011, indicating some impairment in reality testing, the other evidence of record shows that he has never been disoriented to time or place. Further, although evidence shows that he has problems concentrating and focusing, he has not experienced memory loss severe enough that he is unable to remember the names of close relatives. The totality of the evidence shows that his social relationships are severely impaired. However, the September 2011 examiner found that he was not unable to form relationships at all. He and his wife have stayed married for 40 years, despite the strain his symptoms place on their relationship. He also maintains relationships with his children and a cousin who is also a Vietnam veteran. He clearly experiences impaired impulse control in the form of uncontrolled outbursts of anger. However, at no point in the record does the evidence show that he has displayed grossly inappropriate behavior. These symptoms more closely approximate the criteria for a 70 percent evaluation. 38 C.F.R. § 4.130, Diagnostic Code 9411. In June 2011, G. S. stated that the Veteran sometimes could not sustain independent tasks without help. However, neither G. S. nor the Veteran's other health care providers found that he was at any point during the appeals period unable to perform his activities of daily living. Although G. S.'s finding provides some evidence in favor of a 100 percent rating, it is outweighed by the rest of the Veteran's symptoms, which more closely approximate a 70 percent evaluation. In September 2011, the VA examiner found that the Veteran neglected his personal hygiene. However, he also found that the Veteran's PTSD did not cause him to have intermittent inability to perform his activities of daily living or maintain his personal hygiene. The remaining evidence of record shows that he Veteran was casually groomed at his VA treatment appointments. Dr. J. C. and G. S. did not note poor personal hygiene in their statements. Although the September 2011 examiner's finding regarding neglect of personal hygiene provides some evidence in favor of a 100 percent evaluation, it is outweighed by the rest of the Veteran's symptoms, which more closely approximate the 70 percent criteria, as discussed above. Reviewing the evidence, the Board finds that the overall disability picture for the Veteran's PTSD does not more closely approximate a 70 percent rating. 38 C.F.R. § 4.7. The preponderance of the evidence is against the claim so the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. There is no evidentiary basis upon which to assign a rating in excess of 70 percent and since there is no basis for assigning an increased rating, there is no basis for assigning a staged rating. Hart, 21 Vet. App. at 505. The Board has considered whether referral for an extraschedular rating is appropriate under the provisions of 38 C.F.R. § 3.321(b)(1). The threshold factor for extra-schedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). As described above, the manifestations of the Veteran's PTSD are contemplated by the schedular criteria set forth in the General Rating Formula for Mental Disorders. No examiner has reported an exceptional disability picture with symptoms not represented in the rating schedule. In sum, there is no indication that the average industrial impairment from the disability would be in excess of that contemplated by the assigned rating. Accordingly, the Board has determined that referral of this case for extra-schedular consideration is not in order. Bilateral Hearing Loss Impaired hearing will be considered a disability only after threshold requirements are met. See 38 C.F.R. § 3.385. Once a disability is established, levels of hearing loss are determined by considering the pure tone threshold average and speech discrimination percentage scores, resulting in a Roman numeral designation for hearing loss. 38 C.F.R. § 4.85(b), Table VI. Disability ratings are assigned by combining the level of hearing loss in each ear. 38 C.F.R. § 4.85(e), Table VII. See Lendenmann v. Principi, 3 Vet. App. 345 (1992) (assignment of disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered). Table VI, "Numeric Designation of Hearing Impairment Based on Puretone Threshold Average and Speech Discrimination" is used to determine a Roman numeral designation (I through XI) for hearing impairment in each ear based on consideration of speech discrimination as well as pure tone threshold averages, unless the examiner certifies that use of the speech discrimination test is not appropriate. In that case, table VIa, "Numeric Designation of Hearing Impairment Based Only on Puretone Threshold Average" is used. Table VII, "Percentage Evaluation for Hearing Impairment" is then used to determine the percentage evaluation by combining the Roman numeral of each ear. 38 C.F.R. §§ 3.383, 3.385, 4.85(b). If the Veteran has either of two exceptional pattern of hearings impairment, the Roman numeral value is determined using both Table VI and VIa. 38 C.F.R. § 4.86. This method is used if the Veteran's pure tone threshold at each of the four specified frequencies is 55 decibels or more, or if the Veteran's pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. Whichever table results in a higher Roman numeral value is used to calculate a disability evaluation using Table VII. Id. The Veteran's puretone thresholds do not meet the standard for an exceptional pattern of hearing, and therefore Table VIa will not be used to calculate his disability. The Veteran underwent a VA audiology examination in August 2006. His pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -- 25 25 75 85 LEFT -- 25 60 75 80 The average puretone threshold was 53 in the right ear and 60 in the left ear. Speech audiometry revealed speech recognition ability of 94 in the right ear and 84 percent in the left ear. He underwent a second VA examination in September 2011. His pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -- 35 55 75 85 LEFT -- 30 60 75 85 The average puretone threshold was 63 in each ear. Speech audiometry revealed speech recognition ability of 88 in both ears. During the examinations, the Veteran reported that his hearing loss was persistent. This was a sufficient description of the effect of his disability on his daily activities. 38 C.F.R. § 4.10. See Martinak v. Nicholson, 21 Vet. App. 447, 455-56 (2007). The description of the functional effects of the Veteran's hearing disability was not detailed. The Court has noted that even if an audiologist's description of the functional impact of the Veteran's hearing was somehow defective, the Veteran bears the burden of demonstrating any prejudice caused by a deficiency in the examination. There have been no allegations of any prejudice caused by a deficiency in the examinations. Indeed, the Veteran has been represented throughout the course of the appeal, yet the documents submitted do not contain any such assertion. Id., at 455-456. Further, the Veteran's wife provided a statement about the impact of his hearing loss in October 2011. She stated that his hearing has worsened over time and that he has problems understanding people. She stated that she has to repeat herself a lot. Applying the results of the August 2006 examination to Table VI of the VA regulations yields a Roman numeral value of I in the right ear and III in the left ear. Applying these values to Table VII, the Board must find that the Veteran's bilateral hearing loss warrants a noncompensable evaluation. 38 C.F.R. § 4.85. Applying the results of the September 2011 examination to Table VI of the VA regulations yields a Roman numeral value of III in both ears. Applying these values to Table VII, the Board must find that the Veteran's bilateral hearing loss warrants a noncompensable evaluation, and not more. 38 C.F.R. § 4.85. The preponderance of the evidence is against the claim so the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. The Veteran's hearing loss has not met the requirements for a higher rating at any time since the effective date of his award, so the Board may not stage his rating. Fenderson, 12 Vet. App. at 125-26. The Board finds that there is no basis for referral for consideration of an extra-schedular rating in this case. 38 C.F.R. § 3.321(b)(1) (2011). The Veteran has not presented any evidence that his bilateral hearing loss results in a unique disability that is not addressed by the rating criteria. The Veteran's bilateral hearing loss is evaluated under 38 C.F.R. § 4.85, Diagnostic Code 6100, the criteria of which is found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. As noted above, the Veteran's bilateral hearing loss is manifested by, at worst, Level III hearing loss in each ear. When comparing this disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are adequately contemplated by the disability rating for bilateral hearing loss. A rating in excess of the currently assigned rating is provided for certain manifestations of hearing loss, but the medical evidence reflects that those manifestations are not present in this case. The criteria for a noncompensable rating for the Veteran's bilateral hearing loss more than reasonably describe his disability level and symptomatology and, therefore, the currently assigned schedular evaluation is adequate. Thus, there is no basis for referral of the case for consideration of an extraschedular disability evaluation. See Thun v. Peake, 22 Vet. App 111, 115-16 (2008); see also Bagwell v. Brown, 9 Vet. App. 337 (1996). Total Disability Rating Based on Individual Unemployability (TDIU) When entitlement to a TDIU under the provisions of 38 C.F.R. § 4.16 is raised during the adjudicatory process of evaluating the underlying disabilities, it is part of the claim for benefits for the underlying disabilities. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). A TDIU claim is considered reasonably raised when a veteran submits medical evidence of a disability, makes a claim for the highest rating possible, and submits evidence of service-connected unemployability. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). In this case, a TDIU was granted in an October 2012 rating decision and therefore further consideration is not needed. ORDER Service connection for a skin condition is granted. A disability rating in excess of 70 percent for PTSD is denied. A compensable disability rating for bilateral hearing loss is denied. REMAND While the Board regrets the further delay that a remand of this case will cause, the record is not ready for appellate review of the issue on appeal. The following further development is required. A claim for secondary service connection requires medical evidence that connects the asserted secondary disorder to the service-connected disability. Velez v. West, 11 Vet. App. 148, 158 (1998). In order to establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The provisions of 38 C.F.R. § 3.310 were amended, effective October 10, 2006; however, and the new provisions require that service connection not be awarded on an aggravation basis without establishing a pre-aggravation baseline level of disability and comparing it to current level of disability. 71 Fed. Reg. 52744-47 (Sept. 7, 2006). Although the stated intent of the change was merely to implement the requirements of Allen, 7 Vet. App. at 448, the new provisions amount to substantive changes to the manner in which 38 C.F.R. § 3.310 has been applied by VA in Allen-type cases since 1995. The Veteran's claim was pending prior to the effective date of the amended regulation. Consequently, the Board will apply the older version of 38 C.F.R. § 3.310, which is more favorable to the Veteran because it does not require the establishment of a baseline before an award of service connection may be made. With regard to his right knee, right hip, and low back disabilities, the Veteran asserts that they are caused by his service-connected SFW to the right thigh. With regard to his right knee, in September 2011, the Veteran underwent a VA joints examination. The examiner reviewed the Veteran's claims file in conjunction with the examination. He reported that he was hit by a grenade blast and flung through the air, sustaining a SFW to his right thigh. He also reported that he was a paratrooper and fell on his rucksack during a jump. He stated that he had knee pain since his fall. The examiner diagnosed the Veteran with DJD of the right knee and a postoperative medial meniscus tear. The examiner noted that he took into consideration the Veteran's reported history of his injury. The examiner stated that the lack of documentation of a right knee problem at the Veteran's separation examination was evidence against a finding that he has had ongoing knee problems. Further, the examiner noted that VA examinations in 1970 and 1989 found normal joints of the right lower extremity with no evidence of effect from the service-connected SFW. The examiner concluded that there was no evidence of ongoing joint problems caused by the Veteran's service-connected SFW. The examiner concluded that the DJD was caused by age and occupational stresses. He noted that the complaints began in recent years after a period of no complaints. Finally, the examiner explained that the Veteran's DJD was symmetric in areas of his body which is more indicative of occupational stress as a cause, as opposed to trauma. With regard to his right hip disability, in August 2006, the Veteran underwent a VA examination. The examiner reviewed the Veteran's claims file in conjunction with the examination. The Veteran reported that he began to have pain in his left hip, which caused him to compensate with an altered gait, which caused his right hip pain. The examiner found that the Veteran sustained a SFW to the right thigh and walked with an uneven gait. The examiner stated that the Veteran's "complaints and symptoms [were] duly noted." He then concluded that the uneven gait was caused by bursitis or DJD of the right hip and as a result was not due to his SFW. The examiner stated that the hip disability itself was causing the change in gait, not the SFW. The September 2011 VA examination also addressed his right hip. The Veteran reported that he sustained a SFW to the right thigh when he was flung through the air by a grenade blast. He also reported that he was a paratrooper and injured his right hip when he fell during a jump and landed on his rucksack. The examiner diagnosed him with DJD of the right hip. After stating that he took into consideration the Veteran's history of his injury and reported symptoms, he provided a negative opinion. The examiner stated that normal findings at his August 1968 separation examination provide evidence against an ongoing hip problem after his in-service injury. The examiner noted that the Veteran's 1970 and 1989 examinations showed normal joints of the right lower extremity without any impact from his service-connected SFW. The examiner noted that in 1989, DJD of the right hip was suspected because an x-ray suggested subtle DJD, but a follow up hip examination was normal. The examiner concluded that the Veteran's hip problems began around the same time as his back problems, in approximately 2002. The examiner concluded that the Veteran's DJD of the right hip was caused by occupational stress and aging. The examiner noted that the area of the SFW was away from the Veteran's hip. He found that the Veteran's arthritis was symmetric over areas of his body, which is more indicative of being caused by occupational stress instead of trauma. Lastly, with regard to his low back disability, the August 2006 examiner addressed this condition. The Veteran reported back pain. The examiner noted that the Veteran had an uneven gait that was caused by DJD or bursitis of the right hip. The examiner explained that the Veteran's right hip was causing his back pain. He specifically found that the service-connected SFW injury was not the cause of the low back disability. The examiner stated that he took the Veteran's complaints into account when rendering his opinion. The September 2011 VA examiner also addressed the Veteran's low back claim. He reported that he hurt his back either during his SFW injury or when he fell during a parachute jump. He complained of back pain since his injury. He reported that he worked as a mail handler for 30 years after separation from service. The examiner diagnosed him with DJD of the lumbar spine. The examiner stated that he took the Veteran's history and reported symptoms into consideration and found that the low back disability was not caused by service. He found that the Veteran's normal spine on separation from service was evidence against an ongoing low back problem. The examiner noted that the Veteran's 1970 VA examination showed a normal spine. He noted that the first back complaints of record were in 2002, with more beginning in 2006. The examiner concluded that the Veteran's low back disability was caused by age and occupational stress because his complaints started in recent years without earlier complaints in the interim. For the same reasons, the examiner concluded that the Veteran's service-connected SFW injury was noncontributory. Lastly, the examiner noted that the Veteran's DJD was symmetrical in areas of his body, which was more indicative of occupational stress as a cause instead of trauma. The August 2006 and September 2011 VA examiners did not address the aggravation aspect of the Veteran's secondary service connection claims. Specifically, they did not address whether his service-connected SFW to the right thigh aggravated any of the claimed conditions. 38 C.F.R. § 3.310. The Board does not possess the necessary medical expertise to determine whether the Veteran's claimed disabilities were aggravated by his service-connected SFW to the right thigh. Thus, an addendum opinion is required. McLendon v. Nicholson, 20 Vet. App. 79 (2006), see also Colvin v. Derwinski, 1 Vet. App. 171, 174 (1991) (the Board may not make use of its own unsubstantiated medical conclusions); 38 U.S.C.A. § 5103A(d). On remand, the claims file should be returned to the September 2011 VA examiner or another similarly qualified clinician to render an addendum opinion. Accordingly, the case is REMANDED for the following action: 1. Return the Veteran's claims file to the examiner who conducted the September 2011 examination. If that examiner is no longer available, provide the Veteran's claims file to a similarly qualified clinician. A new examination is only required if deemed necessary by the examiner. The purpose of the examination is to determine whether the Veteran has a right knee disability, a right hip disability, and/or a low back disability that had its onset or was aggravated during active service, or manifested to a compensable degree within one year of active service, or is otherwise related to any incident of service, or whether it was caused or aggravated by his service connected SFW to the right thigh. The following considerations will govern the opinion: a) The claims folder and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. b) If a new examination is deemed necessary, the examiner must take a detailed history from the Veteran. If there is any clinical or medical basis for corroborating or discounting the credibility of the history provided by the Veteran, the examiner must so state, with a complete explanation in support of such a finding. c) The examiner must provide an opinion as to whether the Veteran's right knee disability, right hip disability, and/or low back disability began during active service, or is related to any incident during active service, manifested to a compensable degree within one year of active service, or was caused or aggravated by his service-connected SFW to the right thigh. The examiner must specifically address whether the SFW aggravated the claimed conditions. The examiner must specifically address whether the SFW aggravated the Veteran's right knee, right hip, or low back disability. d) The examiner must provide a complete explanation for his or her opinion(s), based on his or her clinical experience, medical expertise, and established medical principles. e) If the examiner is unable to render the requested opinion(s) without resort to speculation, he or she must so state. However, a complete explanation for such a finding must be provided, such as whether there is inadequate factual information, whether the question falls within the limits of current medical knowledge or scientific development, whether the cause of the condition in question is truly unknowable, and/or whether the question is so outside the norm of practice that it is impossible for the examiner to use his or her medical expertise and training to render an opinion. 2. After the above has been completed, the RO must review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action must be implemented. If any report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. 3. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issue on appeal. If the benefits sought on appeal remain denied, in whole or in part, the Veteran and his representative should be provided with a Supplemental Statement of the Case and be afforded reasonable opportunity 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 matter or 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). ______________________________________________ JOHN Z. JONES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs