Citation Nr: 1313813 Decision Date: 04/25/13 Archive Date: 05/03/13 DOCKET NO. 10-46 126 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for simple phobia (driving). 2. Entitlement to an initial rating in excess of 10 percent for residuals of a traumatic brain injury (TBI). 3. Entitlement to a rating in excess of 10 percent for migraine headaches. 4. Whether new and material evidence has been received to reopen a previously denied claim for service connection for a low back disability, and if so, whether service connection is warranted. 5. Whether new and material evidence has been received to reopen a previously denied claim for service connection for a right knee disability, and if so, whether service connection is warranted. 6. Whether new and material evidence has been received to reopen a previously denied claim for service connection for a left knee disability, and if so, whether service connection is warranted. 7. Whether new and material evidence has been received to reopen a previously denied claim for service connection for a left ankle disability, and if so, whether service connection is warranted. 8. Whether new and material evidence has been received to reopen a previously denied claim for service connection for a neuropsychiatric disability, and if so, whether service connection is warranted. ATTORNEY FOR THE BOARD Shamil Patel, Counsel INTRODUCTION The Veteran served on active duty from February 1985 to February 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey. In August 2008, the RO granted service connection for a simple phobia (driving) and assigned a 30 percent disability rating effective December 12, 2007. The RO also continued a 10 percent rating for migraine headaches, and affirmed previous denials for service connection for a low back disability, right knee disability, left knee disability, left ankle disability, and neuropsychiatric disability because no new and material evidence was received. In July 2009, the RO granted service connection for residuals of a TBI and assigned a 10 percent rating effective March 31, 2009. The Veteran filed timely appeals of all the listed issues. A portion of the Veteran's records are contained in the Virtual VA system. Instead of paper, a highly secured electronic repository is used to store and review every document involved in the claims process. The use of this system allows VA to leverage information technology in order to more quickly and accurately decide a Veteran's claim for benefits. Because the current appeal was processed as part of the Virtual VA system, any future consideration of this appellant's case must consider the electronic record. The issues of an increased rating for simple phobia, an increased rating for TBI, an increased rating for migraine headaches, service connection for a left knee disability, and service connection for a right knee 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, D.C. FINDINGS OF FACT 1. The Veteran did not appeal a November 2006 rating decision that denied service connection claims for a low back condition, right knee condition, left knee condition, left ankle condition, and neuropsychiatric condition. 2. Evidence received since the November 2006 rating decision, when considered with previous evidence of the record, does not relate to an unestablished fact necessary to substantiate a claim for a low back disability and does not raise a possibility of substantiating the claim. 3. Evidence received since the November 2006 rating decision, when considered with previous evidence of the record, relates to a previously unestablished fact necessary to substantiate a claim for a right knee condition and raises a possibility of substantiating the claim. 4. Evidence received since the November 2006 rating decision, when considered with previous evidence of the record, relates to a previously unestablished fact necessary to substantiate a claim for a left knee condition and raises a possibility of substantiating the claim. 5. Evidence received since the November 2006 rating decision, when considered with previous evidence of the record, does not relate to an unestablished fact necessary to substantiate a claim for a left ankle condition and does not raise a possibility of substantiating the claim. 6. Evidence received since the November 2006 rating decision, when considered with previous evidence of the record, does not relate to an unestablished fact necessary to substantiate a claim for a neuropsychiatric condition and does not raise a possibility of substantiating the claim. CONCLUSIONS OF LAW 1. The November 2006 rating decision that denied service connection claims for a low back condition, right knee condition, left knee condition, left ankle condition, and neuropsychiatric condition is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.104(a), 3.160(d), 20.302, 20.1103 (2012). 2. New and material evidence has not been received to reopen a claim for service connection for a low back disability. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 3. New and material evidence has been received to reopen a claim for service connection for a right knee disability. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 4. New and material evidence has been received to reopen a claim for service connection for a left knee disability. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 5. New and material evidence has not been received to reopen a claim for service connection for a left ankle disability. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 6. New and material evidence has not been received to reopen a claim for service connection for a neuropsychiatric disability. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159 (2012). Such notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107; 38 C.F.R. §§ 3.159, 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). Prior to the initial adjudication of the Veteran's claims, a letter dated in February 2008 was sent to the Veteran in accordance with the duty to notify provisions of the VCAA. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The Veteran was notified of the evidence that was needed to substantiate her claims; what information and evidence that VA will seek to provide and what information and evidence the Veteran was expected to provide, and that VA would assist her in obtaining evidence, but that it was her responsibility to provide VA with any evidence pertaining to her claims. See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). She was also notified of the criteria for establishing an effective date and disability rating. See Dingess. Specific to requests to reopen previously denied claims, the claimant must be notified of both the reopening criteria and the criteria for establishing the underlying claim for service connection. See Kent v. Nicholson, 20 Vet. App. 1 (2006). In this case, the notice letter provided to the Veteran in February 2008 included the criteria for reopening a previously denied claim, the criteria for establishing service connection, and information concerning why the claims were previously denied. Adequate notice has therefore been provided, as the Veteran was informed about what evidence is necessary to substantiate the elements required to establish service connection that were found insufficient in the previous denials. The Veteran's service treatment records, private treatment records, VA treatment records, and lay statements have been associated with the claims file. No VA examinations have been provided as part of any of the claims being decided on appeal. As discussed below, the Veteran's claims for left and right knee disability are reopened, and VA examinations will be obtained on remand. However, the conduct of VA examinations for the Veteran's requests to reopen claims for entitlement to service connection for a low back disability, left ankle disability, or neuropsychiatric disorder are not appropriate. In the absence of new and material evidence of record, the duty to assist by affording the Veteran a VA examination is not triggered. See 38 U.S.C.A. § 5103A(d), (g); Paralyzed Veterans of Am. v. Sec'y of Veterans Affairs, 345 F.3d 1334, 1353 (Fed. Cir. 2003) (holding that VA need not provide a medical examination or medical opinion until a claim is reopened); Anderson v. Brown, 9 Vet. App. 542, 546 (1996) (holding that unless the veteran has submitted new and material evidence warranting the reopening of his claim, the duty to assist does not attach). As discussed below, new and material evidence has not been submitted for these issues, and reopening the Veteran's claims is not warranted. Therefore, examinations for a low back disability, left ankle disability, and neuropsychiatric disorder are not required. VA has provided the Veteran with the opportunity to submit evidence and argument in support of her claims. The Veteran has not made the Board aware of any additional evidence that needs to be obtained prior to appellate review, and no further action must be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. New and Material Evidence A finally adjudicated claim is an application which has been allowed or disallowed by the agency of original jurisdiction, the action having become final by the expiration of one year after the date of notice of an award or disallowance, or by denial on appellate review, whichever is the earlier. 38 U.S.C.A. § 7105 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.160(d), 20.302, 20.1103 (2012). The claim for entitlement to service connection may be reopened if new and material evidence is submitted. Manio v. Derwinski, 1 Vet. App. 140 (1991). New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate a claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2012). Only evidence presented since the last final denial on any basis will be considered in the context of the entire record. Evans v. Brown, 9 Vet. App. 273 (1996). In determining whether evidence is new and material, the credibility of the new evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). In determining whether new and material evidence has been received to reopen a claim, the Court has indicated that there is a low threshold for determining whether evidence raises a reasonable possibility of substantiating a claim. See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In determining whether this low threshold is met, VA must not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead must consider whether the evidence could reasonably substantiate the claim were the claim to be reopened, including by triggering VA's duty to obtain a VA examination. Id. at 118. Moreover, the Veteran need not present evidence as to each element that was a specified basis for the last disallowance, but merely new and material evidence as to at least one of the bases of the prior disallowance. Id. at 120 (noting the assistance of 38 C.F.R. § 3.159(c)(4) would be rendered meaningless if new and material evidence required a claimant submit medical nexus evidence when he has provided new and material evidence as to another missing element). A. Low Back The Veteran's claim for service connection for a low back disability was most recently denied in a November 2006 rating decision. The RO declined to reopen the Veteran's claim because new and material evidence had not been received. The Veteran did not appeal the November 2006 rating decision, and therefore it is final. In determining whether the claim should be reopened, the reason for the prior denial must be considered. In essence, at the time of the prior denial, the evidence reflected lumbar spine complaints in service and current diagnoses of mild scoliosis and myofascial back pain, but failed to show that the current conditions were related to, or the result of, the Veteran's service. Since the prior final decision, additional evidence has been added to the claims file. Specifically, VA treatment records dated May 2008 reflect a diagnosis of degenerative spondylosis. The evidence submitted is new, as it was not part of the record at the time of the prior final decision. However, it is not material, as it does not relate to a previously unestablished fact necessary to substantiate the Veteran's claim. Specifically, while the evidence reflects a diagnosis of spondylosis, a currently diagnosed condition was already established at the time of the last rating decision. The pertinent question is whether the condition is attributable to service, and the newly submitted evidence does not address that question, does not reasonable raise the possibility of substantiating the claim, and does not warrant reopening for the purpose of a VA examination. See generally Morton v. Principi, 3 Vet. App. 508 (1992); Mingo v. Derwinski, 2 Vet. App. 51 (1992) (observing that evidence of a claimant's current condition is not generally relevant to the issue of service connection, absent some competent linkage to military service). Therefore, new and material evidence has not been received to reopen a previously denied claim for service connection for a left ankle disorder. As the claim is not reopened, the benefit-of-the-doubt standard of proof does not apply. Annoni v. Brown, 5 Vet. App. 463, 467 (1993). B. Right and Left Knees The Veteran's claims for service connection for a right knee condition and left knee condition were most recently denied in a November 2006 rating decision. The Veteran did not appeal the November 2006 rating decision, and therefore it is final. In determining whether the claim should be reopened, the reason for the prior denial must be considered. In essence, at the time of the prior denial, the evidence reflected right and left knee complaints in service, but failed to show current right or left knee conditions that were related to, or the result of, the Veteran's service. Since the prior final decision, additional evidence has been added to the claims file. Private treatment records dated March 2008 show the Veteran complained of bilateral knee swelling and pain. Physical examination only revealed left knee crepitance, and x-rays of both knees were normal. However, the treating physician concluded that the Veteran's history of knee pain dating back to her car accident in service suggests that she must have injured her knees at that time. Additional VA records dated May 2008 reflect findings of effusion and edema in the right knee, and an MCL sprain and lateral meniscus tear in the left knee. The evidence submitted is new, as it was not part of the record at the time of the prior final decision. Moreover, the evidence is material as it relates to the previously unestablished facts of whether the Veteran has current bilateral knee conditions that are related to service. Specifically, the May 2008 VA records reflect physical findings or diagnoses of current knee disorders, and the March 2008 opinion relates current knee symptomatology to service. In light of this new and material evidence, the Veteran's claims for service connection for right and left knee conditions are reopened. As the Board has determined that new and material evidence has been submitted, it is necessary to consider whether the appellant would be prejudiced by the Board proceeding to a decision on the merits. However, as discussed below, additional development is necessary in order to fully adjudicate the Veteran's claims. C. Left Ankle The Veteran's claim for service connection for a left ankle condition was most recently denied in a November 2006 rating decision. The Veteran did not appeal the November 2006 rating decision, and therefore it is final. In determining whether the claim should be reopened, the reason for the prior denial must be considered. In essence, at the time of the prior denial, the evidence reflected left ankle complaints in service and a current diagnosis of left Achilles tendinosis, but failed to show that the current condition was related to, or the result of, the Veteran's service. Since the prior final decision, additional evidence has been added to the claims file, including VA and private treatment records which continue to list left Achilles tendinosis as a diagnosed condition. However, these records do not contain findings or competent medical opinions suggesting that the condition is etiologically related to service. The Veteran's application to reopen her claim, notice of disagreement, and substantive appeal all refer to a left ankle condition manifested by pain and swelling, which she attributes to motor vehicle accidents which occurred during service. However, her statements regarding her condition were already considered at the time of the prior final decision. Therefore, new and material evidence has not been received to reopen a previously denied claim for service connection for a left ankle disorder. Leshore v. Brown, 8 Vet.App. 406 (1995) (the mere transcription of medical history does not transform the information into competent medical evidence merely because the transcriber happens to be a medical professional). As the claim is not reopened, the benefit-of-the-doubt standard of proof does not apply. Annoni v. Brown, 5 Vet. App. 463, 467 (1993). D. Neuropsychiatric Disorder The Veteran's claim for service connection for a neuropsychiatric condition, to include as secondary to migraine headaches, was most recently denied in a November 2006 rating decision. The Veteran did not appeal the November 2006 rating decision, and therefore it is final. In determining whether the claim should be reopened, the reason for the prior denial must be considered. In essence, at the time of the prior denial, the evidence did not reflect a currently diagnosed neuropsychiatric condition or findings of such a condition in service. Since the prior final decision, additional evidence has been added to the claims file, including VA and private treatment records. Notably, these records reflect findings related to the Veteran's service-connected driving phobia and TBI. They also show treatment for posttraumatic stress disorder (PTSD). However, service connection for that specific condition was denied in June 2010. The evidence does not show that the Veteran has a diagnosed neuropsychiatric disorder that is distinct from these other identified conditions. The Veteran's claim to reopen, notice of disagreement, and substantive appeal all refer to a neuropsychiatric disorder without further detail. The Veteran has not presented any new testimony or other evidence to substantiate her claim for service connection for a neuropsychiatric disorder. Her bare statements made in furtherance of her claim were already contained in the claims file and considered in the previous rating decision. Therefore, new and material evidence has not been received to reopen a previously denied claim for service connection for a neuropsychiatric condition. As the claim is not reopened, the benefit-of-the-doubt standard of proof does not apply. Annoni v. Brown, 5 Vet. App. 463, 467 (1993). ORDER The request to reopen a claim for service connection for a low back disability is denied. The claim for service connection for a right knee disability is reopened; the appeal is granted to this extent only. The claim for service connection for a left knee disability is reopened; the appeal is granted to this extent only. The request to reopen a claim for service connection for a left ankle disability is denied. The request to reopen a claim for service connection for a neuropsychiatric disability is denied. REMAND For the following reasons, additional development is warranted in order to fully and fairly adjudicate the claims listed below. Simple Phobia (Driving) The August 2008 rating decision which granted service connection for this disability noted that the Veteran was involved in two motor vehicle accidents in service, once as a pedestrian and another as a driver. The Veteran's most recent VA examination for this disability was in May 2009. However, VA treatment records dated January 2012 show the Veteran reported being hit by a car while crossing a street. Because this incident may have worsened the Veteran's condition, and in light of the fact that her last examination was almost 4 years ago, a new VA examination must be conducted to determine the current severity of the Veteran's driving phobia. See Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993)(VA's duty to assist includes providing a new medical examination when a Veteran asserts or provides evidence that a disability has worsened and the available evidence is too old for an adequate evaluation of the current condition). Moreover, in addition to her service-connected phobia, the Veteran has also been diagnosed and treated for PTSD. Notably, service connection for PTSD was denied in a June 2010 rating decision. Therefore, in evaluating the current severity of the Veteran's phobia, the examiner must, to the extent possible, specify which symptoms are attributable to her service-connected phobia and which symptoms are due to other, nonservice-connected mental disorders. See 38 C.F.R. § 4.14 (2012) (the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation is to be avoided). TBI Service connection is in effect for the residuals of a TBI in addition to the simple phobia discussed above. The rating criteria for TBI residuals acknowledge that there may be an overlap of manifestations of a TBI with manifestations of a co-morbid mental disorder. In such cases, more than one evaluation should not be assigned based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, a single evaluation must be assigned under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning. However, if the manifestations are clearly separable, separate evaluations should be assigned for each condition. See 38 C.F.R. § 4.124a, Diagnostic Code 8045, Note (1). The Veteran TBI residuals were most recently examined in May 2009. The VA examiner attributed a number of symptoms, including mild memory impairment, to the Veteran's TBI. However, VA treatment records dated September 2010 include a notation attributing forgetfulness to depression. Because a new examination is warranted for the Veteran's simple phobia, and in light of the rating criteria discussed above, she must also be afforded a new examination to determine the nature and extent of her TBI residuals. See Weggenmann, supra; see also Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). Migraine Headaches The Veteran is also separately service-connected for migraine headaches. However, similar to the overlap between psychiatric conditions and TBI discussed above, Diagnostic Code 8045 also contemplates an overlap of manifestations of a TBI with manifestations of a co-morbid neurologic disorder, and the rating criteria specifically include headaches as a symptom of TBI. The Veteran's most recent examination for headaches was in April 2009. For the reasons noted above, a new examination addressing the nature and severity of the Veteran's service-connected migraine headaches also must be obtained. Right and Left Knees As noted above, the evidence indicates the Veteran has current bilateral knee conditions, and knee-related complaints were noted in service. Although the March 2008 private physician related the Veteran's knee pain to service, this opinion was not based on any specific current diagnoses. Moreover, the physician stated that the Veteran's history of knee pain since service "suggests" that she injured her knees in service. However, service connection may not be based on speculation or remote possibility. See 38 C.F.R. § 3.102; Obert v. Brown, 5 Vet. App. at 30, 33 (1993) (a medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish a plausible claim); see also Davis v. West, 13 Vet. App. 178, 185 (1999); Bostain v. West, 11 Vet. App. 124, 127-28 (1998). Therefore, the Veteran must be afforded a VA examination to determine the exact nature and etiology of her knee disabilities. Accordingly, the case is REMANDED for the following action: 1. The AMC/RO must schedule the Veteran for a VA examination to ascertain the current severity and manifestations of her traumatic brain injury residuals, driving phobia, and migraine headaches. Any and all studies, tests, and evaluations deemed necessary by the examiner must be performed. The examiner must review all pertinent records associated with the claims file. The following considerations will govern the examination: (a) 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. (b) The examiner must determine, to the extent possible, which symptoms are associated with the Veteran's service-connected driving phobia, which symptoms are associated with her service-connected TBI residuals, and which symptoms are associated with diagnosed but nonservice-connected psychiatric disabilities such as PTSD. If the manifestations cannot clearly be distinguished, the examiner must clearly state that fact. (c) For manifestations attributable to a service-connected driving phobia, the examiner must identify the nature, frequency, and severity of these symptoms, and assign a GAF score and provide an explanation of the assigned score. (d) For manifestations attributable to a service-connected TBI, the examiner must report the severity of such TBI residuals in a manner consistent with the new schedular criteria for evaluating residuals of TBI under 38 C.F.R. § 4.124a, Diagnostic Code 8045. This includes evaluations of memory, attention, concentration, and executive functions; judgment; social interactions; orientation; motor activity; visual spatial orientation; subjective symptoms; nonbehavioral effects; communication; and consciousness. (e) With regard to headaches, the examiner must render specific findings as to the frequency and severity of the Veteran's headaches, specifically indicating whether the Veteran suffers very frequent, completely prostrating attacks productive of severe economic inadaptability; characteristic prostrating attacks occurring on average once a month; characteristic prostrating attacks averaging one in two months; or less frequent attacks. The examiner must assess whether headaches require rest periods during most days. The examiner must set forth all examination findings, along with the complete explanation for the conclusions reached. A clear explanation for all opinions is required to include a discussion of the facts and medical principles involved. 2. The AMC/RO must schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran's claimed left and right knee disabilities. The following considerations will govern the examination: a. The claims folder and a copy of this remand will be reviewed by the VA examiner, who must acknowledge such review in the report generated by this remand. b. After reviewing all evidence of record, interviewing the Veteran, and conducting a physical examination, the VA examiner must identify all diagnosed left and right knee conditions, and state whether any of these conditions were incurred in, or are etiologically related to, the Veteran's military service. c. The VA examiner must independently review the record for pertinent evidence, but his or her attention is called to the following: i. Service treatment records dated December 1985 showing the Veteran was struck by a car and treated for bruises and abrasions on both legs. ii. Service treatment records dated October 1986 showing the Veteran complained of right knee edema following another car accident, and being diagnosed with a bruise. iii. Service treatment records dated July 1987 showing complaints of bilateral knee pain and diagnoses of patellofemoral chondritis. iv. Service treatment records dated August 1987 showing complaints of bilateral knee swelling, minimal findings of swelling with normal range of motion, and a diagnoses of knee pain, etiology unknown, probable arthritis. v. Service treatment records dated March 1988 showing complaints of right knee swelling and a diagnosis of patellofemoral chondritis. vi. A January 1989 separation examination indicating normal findings of the lower extremities, and an accompanying report of medical history which noted that the Veteran was "found to have patellofemoral chondritis - now stable." vii. Post-service complaints of knee pain and stiffness. viii. VA treatment records dated February 2006 showing normal x-ray findings of both knees. ix. A March 2008 private opinion attributing current bilateral knee pain to car accidents in service. x. VA treatment records dated May 2008 showing findings of effusion and edema in the right knee, and an MCL sprain and lateral meniscus tear in the left knee. d. The VA examiner must state the medical basis for any opinion rendered, with reference to pertinent evidence of record. It is critical the VA examiner review all evidence of record and fully state the medical basis or bases for any opinions rendered. The VA examiner's stated expertise in and of itself is not a sufficient statement under the law upon which to evaluate a medical opinion. e. If the VA 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. 3. Following completion of the above directives, the AMC/RO must review the claims folder and ensure that all of the foregoing development has been conducted and completed in full. In particular, the AMC/RO must determine whether the examiners have responded to all questions posed. If not, the report must be returned for corrective action. 38 C.F.R. § 4.2 (2012). 4. After completing the above actions and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims must be readjudicated. If any claim remains denied, an SSOC must be provided to the Veteran. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. 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). ______________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs