Citation Nr: 1314175 Decision Date: 04/30/13 Archive Date: 05/15/13 DOCKET NO. 09-05 059 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for a left knee disability. 3. Entitlement to service connection for coronary artery disease with left ventricular hypertrophy and mitral valve regurgitation, status post angioplasty. 4. Entitlement to an initial compensable rating before October 9, 2006, and an initial rating higher than 10 percent beginning October 9, 2006, for degenerative disc disease of the cervical spine with bilateral upper extremity radiculopathy. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Debbie A. Breitbeil, Counsel INTRODUCTION The Veteran, who is the appellant, had honorable service from June 1979 to September 1992 and from January 2003 to April 2005, in addition to service in the Army Reserve. This matter is before the Board of Veterans' Appeals (Board) on appeal of an October 2005 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In a December 2008 rating decision, the RO granted a 10 percent rating for degenerative disc disease of the cervical spine with bilateral upper extremity radiculopathy, effective October 9, 2006. The Veteran continued his appeal for a higher initial rating. In September 2012, the Veteran appeared at the RO and testified in a hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file. The issue of a higher initial rating for degenerative disc disease of the cervical spine with bilateral upper extremity radiculopathy is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center in Washington, DC. FINDINGS OF FACT 1. There is competent medical evidence to show that the Veteran has a low back disability that had onset during active service. 2. There is competent medical evidence to show that the Veteran has a left knee disability that had onset during active service. 3. Coronary artery disease with left ventricular hypertrophy and mitral valve regurgitation, status post angioplasty, is not shown by clear and unmistakable evidence to have pre-existed the Veteran's active service; and there is competent medical evidence to show that the coronary artery disease with left ventricular hypertrophy and mitral valve regurgitation, status post angioplasty, had onset during active service. 4. Alternatively, assuming clear and unmistakable evidence shows coronary artery disease with left ventricular hypertrophy and mitral valve regurgitation, status post angioplasty, pre-existed the Veteran's active service, rebutting the presumption of soundness on enlistment, the evidence does not clearly and unmistakably show that the disability did not permanently worsen beyond natural progression during active service. CONCLUSIONS OF LAW 1. A low back disability was incurred in active service. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2002); 38 C.F.R. § 3.303 (2012). 2. A left knee disability was incurred in active service. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2002); 38 C.F.R. § 3.303 (2012). 3. Service connection for coronary artery disease with left ventricular hypertrophy and mitral valve regurgitation, status post angioplasty, is warranted. 38 U.S.C.A. §§ 1110, 1111, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim. As the claims of service connection for a low back disability and a left knee disability are resolved in the Veteran's favor, VCAA compliance need not be addressed further. Principles of Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). Service connection may also be granted for a 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) (2012). Certain chronic diseases, including arthritis, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. § 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). A Veteran is presumed to have been in sound condition when examined, accepted, and enrolled for service except as to defects, infirmities, or disorders noted at the time of examination, acceptance, enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the "correct standard for rebutting the presumption of soundness under section 1111 requires the government to show by clear and unmistakable evidence that (1) the veteran's disability existed prior to service and (2) that the pre-existing disability was not aggravated during service." Wagner v. Principi, 370 F.3d 1089, 1097 (Fed. Cir. 2004). In determining whether a condition preexisted service, the veteran's medical history, accepted medical principles, evidence regarding the basic character, origin and development of the condition, and lay and medical evidence concerning the inception, development and manifestations of the condition must be considered. 38 C.F.R. § 3.304(b); see Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009). VA must give due consideration to all pertinent medical and lay evidence in a case where a veteran is seeking service connection. 38 U.S.C.A. § 1154(a). The Veteran does not argue, and the record does not show, that the claimed disorders were the result of participation in combat with the enemy. Thus, the provisions of 38 U.S.C.A. § 1154(b) do not apply. Competency is a legal concept in determining whether medical or lay evidence may be considered, in other words, whether the evidence is admissible as distinguished from weight and credibility, a factual determination going to the probative value of the evidence, that is, does the evidence tend to prove a fact, once the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis, statement, or opinion. 38 C.F.R. § 3.159. The Board, as fact finder, must determine the probative value or weight of the admissible evidence. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005) (citing Elkins v. Gober, 229 F.3d 1369, 1377 (Fed.Cir.2000) ("Fact-finding in veterans cases is to be done by the Board")). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Facts and Analysis Initially, the Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. The Board acknowledges that additional evidence has been added to the claims file since the RO last adjudicated these service connection claims in a December 2008 statement of the case. This evidence includes VA examination reports dated in July 2009 and a private physician's statement (Dr. Fried) of February 2009. Such evidence has not been considered by the RO, and the Veteran has not specifically waived his right to have the RO initially review it. Nevertheless, given the Board's determination that the benefits to which the evidence relates should be fully allowed on appeal, and the Veteran will not be prejudiced by a Board decision on those claims (low back, left knee, coronary artery disease) at this juncture, it will decide the claims rather than refer them back to the RO. The Veteran contends that the onset of his disabilities affecting his low back, left knee, and heart was during the period of active service that ended in 2005. In statements and testimony, he asserted that his back and left knee problems began during his second period of service from January 2003 to April 2005. Additionally, he maintains that it was also during this time that he first experienced problems with his heart, namely, angina, arm numbness, and aching in the jaw. As to his low back, he stated he was diagnosed with a strain shortly before his separation and that he received back treatment several times in the months following his military retirement in 2005. As to his left knee, he notes that during service he was diagnosed with degenerative joint disease of both of his knees but that only his right knee has been service connected. As to his heart, he asserted that one of his cardiologists (Dr. Culclasure), who provided a supporting medical opinion, did in fact review his entire record before rendering an opinion. Further, he argued that clear and unmistakable evidence has not been presented to show his cardiac condition pre-existed his service that began in January 2003, and that even if it was assumed that his heart condition pre-existed service, there is not clear and unmistakable evidence to show that it was not permanently aggravated beyond natural progression during service. The Veteran served two periods on active duty, in addition to service in the Army Reserve: from June 1979 to September 1992, and from January 2003 to April 2005. Prior to service in January 2003, private records from Cardiac Disease Specialists dated in November 2002 show that the Veteran was referred there with a history of chest pain, shortness of breath, and hypertension. It was noted that he had had an echocardiogram in January 2001, showing normal left ventricular dimensions with mild concentric left ventricular hypertrophy and a mild mitral regurgitation. A repeat echocardiogram was done in April 2002, showing concentric left ventricular hypertrophy, ejection fraction of 60 percent, and mild mitral and tricuspid regurgitation. The Veteran complained of an "ache" that had developed in his chest. An electrocardiogram was done, which was normal with some mild nonspecific ST-T wave abnormalities. The assessment included increased dyspnea and chest pressure - rule out cardiac etiology. In December 2002, a myocardial perfusion was normal. The Veteran entered service for the second time in January 2003. Service personnel and treatment records show, among other things, the following: in January 2003, the Veteran complained of pain and giving way of his knees after exercising, with X-rays that showed mild patellofemoral syndrome and degenerative joint disease; the Veteran was given a physical profile in January 2003 regarding various restrictions on running and jumping for his knees; in Kuwait in April 2003, he developed left arm numbness, burning in the chest, and aching in the jaw, and was medivaced to Landstuhl, Germany for treatment for blocked arteries (100 percent of the right collateral artery and 99 percent of the obtuse marginal artery) to include angioplasty and stent, which was followed by multiple stenting procedures due to restenosis; in January 2004, the Veteran was seen for increasing bilateral knee complaints and it was noted he had a great deal of trouble with them when activated to Kuwait in 2003 and his diagnosis was mild patellofemoral osteoarthritis; the Veteran received treatment in April 2004 for his knees, diagnosed as bilateral patellofemoral pain syndrome and degenerative joint disease; on a December 2004 report of medical history, the Veteran reported shortness of breath and pain in his chest related to coronary artery disease, chronic arthritis in the knees, and chronic lower back pain; a December 2004 physical examination report indicated diagnoses of coronary artery disease, bilateral knee degenerative joint disease, and low back pain; and in February 2005 in a memorandum for the Physical Evaluation Board, a cardiologist opined that the Veteran "undoubtedly" had coronary artery disease prior to deployment but that it was possible that certain stressors in service could have aggravated his cardiac condition. Prior to his separation from service in April 2005, the Veteran underwent a VA general medical examination in March 2005. He said he has suffered from pain in the lower back for one year. He said a bilateral knee condition with pain, swelling, and instability has existed since 2003, from straining to carry heavy loads during combat service. He related that he has suffered from coronary artery disease since 2003, with symptoms of constant angina, shortness of breath, and fatigue. X-rays of the lumbar spine and left knee were within normal limits. An EKG showed normal sinus rhythm with non-specific ST and T wave changes. An echocardiogram was abnormal, showing moderate left ventricular hypertrophy with an ejection fraction of 65 percent, and mild mitral and tricuspid insufficiency of no pathological significance. The diagnoses were chronic low back strain, chronic left knee strain, left ventricular hypertrophy, mitral regurgitation, and coronary artery disease status post angioplasty with stent. After service, the Veteran continued to receive treatment for disabilities affecting his low back, left knee, and heart. For example, in October 2006, Dr. Fried noted that X-rays of the lumbar spine showed some mild spurring at L4-5, which was compatible with mild degenerative disc disease. The assessment was lower back pain and leg pain, probably with some degenerative disc disease. A March 2007 private MRI of the lumbar spine showed L4-5 right lateral disc/osteophyte complex with encroachment against the lateral neural foramen and likely abutment of the L4 nerve root; and L5-S1 annular disc bulging with no associated significant central canal or foraminal stenosis. In May 2007, he was seen at the Georgia Heart & Vascular Center, where Dr. Culclasure indicated after an evaluation that the Veteran was still experiencing low level exertional angina symptoms despite multiple interventions and compliance with his medical regimen. The physician noted that the Veteran's condition was permanent and stable related to coronary artery disease in RCA (right collateral artery) and OM (obtuse marginal artery). In the report, the physician noted the Veteran's medical history, to include 2-vessel abstract cardiac disease initially diagnosed in Germany in April 2003 with cardiac angioplasty and stenting at that time, and multiple recurrent catheterization and requirements for further stenting in the circumflex artery. A July 2008 visit to Dr. Fried, who noted the Veteran still complained of some back pain and leg pain; the assessment was lumbar disc disease. In October 2008, the RO scheduled a VA examination to determine the nature and etiology of the Veteran's current left knee disability, to include whether it was related to, or had onset during, his period of active service. The Veteran reported having pain in his knees while at Fort Benning during mobilization training for deployment, after which he was put on a physical profile to limit his jumping and running. He complained of continued knee problems. X-rays of the left knee were negative. The diagnosis was degenerative joint disease of the left knee as evidenced by palpable and audible crepitus on physical examination in spite of negative X-rays. As the examiner did not furnish a medical opinion regarding onset of the left knee disability, the Veteran was afforded another VA examination in July 2009. After reviewing the record, the examiner diagnosed the Veteran with mild degenerative joint disease of the left knee with patellofemoral pain syndrome. The examiner concluded that it was likely that the Veteran's left knee condition was related to his military duty, particularly as he had been evaluated while on active duty for left knee pain and had radiographic evidence then showing degenerative changes. In July 2009, the Veteran also underwent a VA examination to determine the nature and etiology of his low back disability. At the time, the Veteran reported that he developed low back pain around 2003, which was a gradual onset, and that he continued to suffer with back pain after he was deployed to Kuwait but was not evaluated as other medical problems took precedence. He indicated that he was treated with muscle relaxers at some point and told he had a back strain. After service, he sought treatment with Dr. Fried, who finally ordered an MRI that revealed various degenerative changes. After evaluation, the VA examiner diagnosed disc osteophyte complex at L4-5 with right neuroforaminal narrowing and mild to moderate broad-based bulging disc at L5-S1. The examiner concluded that it was at least as likely as not that the Veteran's back condition was related to his military service, noting the following factors. There was no CT or MRI performed while in active service, the Veteran's back pain has been persistent and continuous since then, he began to see Dr. Fried shortly after service, and he had abnormal findings on an MRI in 2007. In relation to the low back and left knee evaluations, the VA examiner considered the Veteran's medical history, described the disabilities in sufficient detail, and rendered an opinion supported by the facts and a reasoned explanation, connecting the facts and the conclusion, so that the Board's decision is a fully informed one. In sum, the VA examiner's opinions are highly probative of the question regarding the onset of the low back and left knee disabilities, and there is no evidence of greater weight against the claims. In fact, there is no contrary opinion regarding onset in the claims file. It is also noted that Dr. Fried provided an opinion in February 2009, which is consistent with that VA opinion of July 2009 relative to the low back. Dr. Fried indicated that he reviewed the Veteran's medical record to include service treatment records that showed a diagnosis of chronic low back pain and limited range of motion while on active duty. He opined that the Veteran had continued back pain with lumbar degenerative disc disease that was related with reasonable medical probability to his original low back condition in service. In view of the foregoing medical and lay evidence, the Board finds that there is sufficient evidence to substantiate the claims of service connection for a low back disability and a left knee disability. Specifically, given the documented low back and left knee symptoms during service which continued after separation from service in April 2005, and the favorable medical opinions of the VA examiner and Dr. Fried (regarding the low back only) to the effect that the Veteran's current disabilities of the low back and left knee had onset during service, the Board finds that the evidence supports the Veteran's claims of service connection for a low back disability and a left knee disability, and his claims are granted. With regard to the Veteran's coronary artery disease with left ventricular hypertrophy and mitral valve regurgitation, status post angioplasty, the question of the onset, or aggravation of the disability during service, is not so easily answered. The record contains medical opinions that are both supportive and not supportive of the Veteran's claim. The Veteran private cardiologist presented statements in support of the claim. In a September 2007 statement, Dr. Culclasure indicated that medical records of the Veteran dated before (2002) and during service (beginning January 2003) were reviewed, and based on that information it was determined that it was "just as likely as not" that the Veteran's coronary artery disease manifested while he was participating in combat operations during Operation Iraqi Freedom. In the report, the physician in particular noted the following: cardiac testing performed in December 2002, where the results were reported as normal with no signs of coronary artery disease; a military doctor's mobilization examination in January 2003, which resulted in a finding of no signs of coronary artery disease; and military records showing that the Veteran was medivaced from Kuwait in April 2003 to Landstuhl, Germany where he was diagnosed with two-vessel coronary artery disease and underwent angioplasty, followed by multiple recurrent angioplasty and stent placements for the same condition through service. In July 2008, Dr. Culclasure stated that the Veteran had been his patient since August 2005 when the Veteran was referred to him by his military doctor for coronary artery disease that first occurred while he was on active duty. In October 2008, a VA medical opinion was obtained to address whether coronary artery disease began or first manifested during active duty, and if it was pre-existing service whether it was aggravated due to military service. The examiner, an interventional cardiologist (who also provided a similar medical opinion to the military Physical Evaluation Board in February 2005), noted pertinent evidence prior to and during service and opined that (1) coronary artery disease pre-existed service (despite there being no diagnosis until service) and that (2) it was at least as likely as not that the Veteran's military service exacerbated his pre-existing symptoms and led to the finding of coronary artery disease in April 2003. As for the second of these opinions, the examiner added that the recurrence of blockage and need for repeat coronary artery interventions after April 2003 "were most likely a result of natural disease progression and not a result of aggravation due to military service." The RO sought clarification of this seemingly contradictory opinion, and in a December 2008 report the examiner briefly remarked that it was her "best medical opinion that the veteran's disease was not at least as likely as not permanently worsened by his active mild service (less than 50% probability)." An explanation of rationale was not furnished. With regard to both the private and VA opinions, it is noted that the examiners did not provide conclusions that adhered to the correct standard of review in this case, which is "clear and unmistakable" (and not "at least as likely as not"). Moreover, both opinions differed as to whether the Veteran's coronary artery disease pre-existed service. Under the law, if coronary artery disease was not noted on the Veteran's entrance (or re-enlistment, in this case) examination, the presumption of soundness attaches (see 38 U.S.C.A. § 1111) and the burden then falls on VA to rebut the presumption of soundness by clear and unmistakable evidence that the Veteran's disability was both preexisting and not aggravated by service. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed.Cir.2004). Clear and unmistakable evidence means evidence that cannot be misinterpreted and misunderstood, that is, the evidence is undebatable. Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009) (quoting Vanerson v. West, 12 Vet. App. 254, 258-59 (1999). In this case, coronary artery disease was not definitively diagnosed until April 2003, which is months into the Veteran's second period of active service. The Veteran's private cardiologist appears to take the position that the Veteran's coronary artery disease manifested, or had onset, during service. Conversely, the VA examiner found that the extent of the Veteran's stenosis (occlusion of 99 percent and 100 percent, respectively, in two vessels) in April 2003 reflected a disease process that would have existed prior to service, and that the Veteran had been evaluated prior to service for underlying cardiac symptoms. The VA examiner also cited to a private physician, who in an August 2003 cardiology evaluation appeared to relate that the Veteran had stenosis (at least in the obtuse marginal vessel) in December 2002 that "subsequently became more critical." Thus, although it certainly seems reasonable to find that the evidence demonstrates underlying coronary artery disease existed prior to service entrance in January 2003, there is a higher standard of review at play here. Where such condition is not noted on an enlistment physical examination, there must be clear and unmistakable evidence that it pre-existed service. Given the varying medical opinions on this point, it seems that the matter is debatable and thus cannot meet the required "clear and unmistakable" standard to rebut the presumption of soundness found at enlistment. In short, VA has not met the high burden to show coronary artery disease existed prior to service, and with the clear evidence of a diagnosis of coronary artery disease in service followed by a chronic disability requiring continuous cardiac treatment, the Board finds that the evidence supports the Veteran's claim, and his claim is granted. Even if the evidence clearly and unmistakably shows that coronary artery disease pre-existed service (such as the cardiologist's statement in February 2005 to the Physical Evaluation Board that the Veteran "undoubtedly had underlying atherosclerotic coronary artery disease present prior to deployment" and the clear clinical findings of mild left ventricular hypertrophy and mitral regurgitation in the early 2000s), thus rebutting the presumption of soundness on enlistment, VA would still have the burden of demonstrating that the pre-existing disability did not permanently worsen, beyond natural progression, during service. Initially, the VA examiner in October 2008 concluded that it was as likely as not that military service exacerbated pre-existing symptoms, and that the subsequent recurrent blockage and cardiac interventions were a result of the natural progression of the disease and not aggravation by service. The VA examiner's clarifying opinion again employed the incorrect reviewing standard, stating that it was not at least as likely as not that the cardiac condition was permanently worsened by service. This same VA examiner earlier provided a statement in February 2005 to the Physical Evaluation Board, indicating that it was "certainly possible, however, that the stressors of serving in a combat environment, to include unaccustomed physical activity, altered sleep patterns, and dietary changes could have aggravated [the Veteran's] cardiac condition." These findings leave open for debate the question of aggravation of the cardiac condition during service. Further, combined with the service treatment records showing essentially the Veteran's acceptance for deployment followed by medical evacuation from Kuwait, multiple cardiac procedures beginning in Germany, and continual cardiac monitoring through service to the present, the Board finds that the evidence would still support the Veteran's claim of service connection for coronary artery disease with left ventricular hypertrophy and mitral valve regurgitation, status post angioplasty, but on an aggravation basis. ORDER Service connection for a low back disability is granted. Service connection for a left knee disability is granted. Service connection for coronary artery disease with left ventricular hypertrophy and mitral valve regurgitation, status post angioplasty, is granted. REMAND Regarding the issue of a higher initial rating for degenerative disc disease of the cervical spine with bilateral upper extremity radiculopathy, the record indicates that there are two VA examinations (in March 2005 with an addendum in May 2005, and February 2009) and private medical treatment records (particularly from Dr. Fried), which are pertinent to the increased rating claim. Preliminarily, it appears that the Veteran's cervical spine disability has progressively worsened over time. However, the clinical findings on the latest VA examination in February 2009 are not sufficient in order to evaluate the disability, as will be explained below. Moreover, it does not appear that the RO considered the February 2009 VA examination report prior to transferring the claims file to the Board for its review. Notably, the examiner on the VA neurological examination in February 2009 concluded that the Veteran's diagnosed multilevel cervical degenerative joint disease and degenerative disc disease with upper extremity radiculopathy (as shown on an EMG) is moderately disabling. Evaluation at that time showed decreased sensation and 3/5 strength without muscle atrophy, and 2/2 reflexes in the upper extremities related to the cervical spine disability. In order to rate the Veteran's objective neurological abnormalities of the cervical spine disability under the appropriate diagnostic code(s) for diseases of the peripheral nerves, it is necessary that the particular associated nerve or nerves of the upper extremities are identified. The Schedule for Rating Disabilities (Part 4) provides various ratings according to whether one or more of the following nerves are affected: upper radicular group, middle radicular group, lower radicular group, all radicular groups, musculospiral nerve (radial nerve), median nerve, ulnar nerve, musculocutaneous nerve, circumflex nerve, and long thoracic nerve. In light of the foregoing, the RO should arrange to have the Veteran's cervical spine disability with associated neurological impairment re-evaluated. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA orthopedic and neurological examination to ascertain the nature and severity of the Veteran's service-connected degenerative disc disease of the cervical spine with bilateral upper extremity radiculopathy. The claims folder should be made available to the examiner for review. The examiner should undertake any development deemed necessary, to include range of motion testing of the cervical spine and any electromyography/nerve conduction studies. The examiner is asked specifically to address, with regard to any limitation of motion, whether there is additional loss of function and pain on motion under DeLuca v. Brown, 8 Vet. App. 202 (1995). The examiner is also asked to specify all nerves affected (e.g., upper/middle/lower radicular group, radial, median, ulnar, musculocutaneous, circumflex, long thoracic) and their degree of lost or impaired function. To that end, descriptions of impairment characterized as mild, moderate, and severe would be helpful. It should also be noted whether or not any nerve involvement is wholly sensory. 2. Following completion of the foregoing development, adjudicate the claim. If the benefit sought on appeal remains denied, furnish the Veteran and his representative a supplemental statement of the case and return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter 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 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). ______________________________________________ ROBERT E. SULLIVAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs