Citation Nr: 1315306 Decision Date: 05/09/13 Archive Date: 05/15/13 DOCKET NO. 10-22 468A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to an initial evaluation in excess of 20 percent for diabetes mellitus. 2. Entitlement to an initial evaluation in excess of 10 percent for peripheral neuropathy of the right lower extremity. 3. Entitlement to an initial evaluation in excess of 10 percent for peripheral neuropathy of the left lower extremity. 4. Entitlement to service connection for erectile dysfunction, to include as secondary to diabetes mellitus. 5. Entitlement to special monthly compensation due to loss of use of a creative organ. REPRESENTATION Appellant represented by: Missouri Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Barone, Counsel INTRODUCTION The Veteran had active service from January 1970 to December 1972. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at the RO in March 2013. A transcript of the hearing has been associated with the Veteran's Virtual VA (VVA) e-file. The issues of entitlement to service connection for erectile dysfunction and special monthly compensation 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. During the appeal period, diabetes mellitus has required oral agents and insulin and a restricted diet, but there is no medical evidence of a restriction of activities required by a physician. 2. Peripheral neuropathy of the right lower extremity is manifested by mild incomplete paralysis of the sciatic nerve. 3. Peripheral neuropathy of the left lower extremity is manifested by mild incomplete paralysis of the sciatic nerve. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.119, Diagnostic Code 7913 (2012). 2. The criteria for an initial evaluation in excess of 10 percent for peripheral neuropathy of the right lower extremity have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2012). 3. The criteria for an initial evaluation in excess of 10 percent for peripheral neuropathy of the left lower extremity have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (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); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable RO decision on a claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). On March 3, 2006, the Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id. at 486. A letter dated in January 2009, prior to the adjudication of the Veteran's diabetes claim, discussed the evidence necessary to establish service connection for diabetes mellitus. The evidence of record was listed and the Veteran was told how VA would assist him in obtaining additional relevant evidence. He was also advised of the manner in which VA determines disability ratings and effective dates. A letter dated in March 2010, prior to the adjudication of the Veteran's lower extremity peripheral neuropathy claim, discussed the evidence necessary to establish service connection for peripheral neuropathy. The evidence of record was listed and the Veteran was told how VA would assist him in obtaining additional relevant evidence. He was also advised of the manner in which VA determines disability ratings and effective dates. The Board finds that the content of the notice provided to the Veteran fully complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. The Veteran has been provided with every opportunity to submit evidence and argument in support of his claim and to respond to VA notices. Further, the Board finds that the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claims. Therefore, the record reflects that he was provided with a meaningful opportunity during the pendency of his appeal such that the preadjudicatory notice error did not affect the essential fairness of the adjudication now on appeal. The Board notes that this is a case in which the Veteran is challenging the initial evaluation assigned following the grant of service connection for diabetes mellitus and lower extremity peripheral neuropathy. In Dingess, the Court of Appeals for Veterans Claims held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. With respect to VA's duty to assist, VA treatment records and private treatment records have been obtained and associated with the record. VA examinations have been conducted. The Board finds that the examinations were adequate in that they were conducted by neutral, skilled providers who reviewed the record, interviewed the Veteran, and performed appropriate physical examinations prior to providing their conclusions. The Veteran also was afforded a hearing before the undersigned during which he presented oral argument in support of his claim. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ or Decision Review Officer who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ fully explained the issues on appeal during the hearing and asked questions specifically regarding the elements necessary to establish the benefits sought. Significantly, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the evidence necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the evidence necessary to substantiate his claims. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). The Veteran has not otherwise identified any additional evidence or information which could be obtained to substantiate the claim. The Board is also unaware of any such outstanding evidence or information. Therefore, the Board is also satisfied that VA has complied with the duty to assist requirements of the VCAA and the implementing regulations. For the foregoing reasons, it is not prejudicial to the appellant for the Board to proceed to a final decision in this appeal. Analysis Disability ratings are based upon schedular requirements that reflect the average impairment of earning capacity occasioned by the state of a disorder. 38 U.S.C.A. §1155. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4 (2012). In determining the level of impairment, the disability must be considered in the context of the entire recorded history, including service medical records. 38 C.F.R. §4.2 (2012). An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. §4.10 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. §4.7 (2012). The Board observes that in cases where the original rating assigned is appealed, consideration must be given to whether a higher rating is warranted at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). The Board has considered whether staged ratings are warranted. It has determined that the disabilities in question have not significantly changed, and that uniform ratings are for application. Diabetes Mellitus Private treatment records associated with the claims file indicate new onset diabetes in May 2008. An August 2009 VA treatment record reflects the Veteran's report of diabetes of two years' duration. He noted that he had tried various oral medications. On VA examination in October 2009, the Veteran reported that he was on oral agents and that he had never been on insulin. In April 2010 the Veteran was noted to continue on an oral agent. On VA examination in July 2012, the Veteran's history was reviewed. The examiner noted that the Veteran's diabetes was managed by restricted diet, oral hypoglycemic agents, and prescribed insulin. He specified that regulation of activities was not required. He also noted that there had been no episodes of ketoacidosis or hypoglycemic reaction requiring hospitalization in the previous 12 months. During his March 2013 hearing, the Veteran testified that physical activity such as mowing the grass, playing with his grandchildren, and shopping wore him out. 38 C.F.R. § 4.119, Diagnostic Code 7913 provides for ratings based on diabetes mellitus. Diabetes that requires insulin and a restricted diet or oral hypoglycemic agents and restricted diet warrants a 20 percent evaluation. A 40 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. A 60 percent disability rating requires insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately rated. A 100 percent rating requires more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119, DC 7913. Regulation of activities is defined by Diagnostic Code 7913 as the "avoidance of strenuous occupational and recreational activities." Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360, 363-364 (2007). Having carefully considered the evidence pertaining to the Veteran's diabetes mellitus, the Board finds that an evaluation in excess of 20 percent for diabetes mellitus is not warranted. In that regard, the Board observes that the Veteran is not restricted in his ability to perform strenuous activities due to his diabetes mellitus. As noted, restriction of activities is defined by the regulation as the avoidance of strenuous occupational and recreational activities, and requires medical evidence to establish this fact. In this case, there is no medical evidence indicating that restriction of activities has been prescribed by a medical provider in order to help control the Veteran's diabetes. Rather, the Veteran has merely stated that physical activity wears him out. While the Veteran is competent to describe his symptoms, in the case of regulation of activities, his testimony is not sufficient to establish the higher rating. In summary, the Board finds that the criteria for a higher 40 percent evaluation for diabetes mellitus have not been met. While the Veteran is prescribed both oral agents and insulin for the control of his diabetes, there is no indication of medically required regulation of activities due to his diabetes. The 20 percent rating is appropriate throughout the appeal. Peripheral Neuropathy On VA examination in May 2010, the Veteran's history was reviewed. Physical examination revealed normal reflexes at the knees. Reflexes were barely obtainable at the ankles. Vibratory sensation was present, but reduced at both great toes. Monofilament produced absent responses at the second and fourth toes of the right foot and blunted but perceptible responses at the first, third, and fifth toes of the right foot. The Veteran had very little sensation to the 10 gram monofilament in the lateral aspect of the ball of the right foot, and it was absent medially. He had blunted, but better perception of the instrument as it was brought across the instep and hind foot on the right. On the left, he had blunted but perceptible sensation under the first, third, fourth, and fifth toes, but not under the second. The lateral aspect of the ball of the left foot was barely able to perceive the instrument with better acuity medially and in the instep as the instrument was brought more proximally. The Veteran was able to appreciate a very cold tuning fork laid across his toes dorsally. He was able to appreciate such at the calves. The examiner noted that the Veteran's gait and station were normal and he was independently ambulatory. The diagnosis was peripheral neuropathy of the lower extremities. The examiner noted that the Veteran had no intrinsic muscle atrophy of the feet. In May 2010, a VA provider noted that there was no discoloration or lesions of the skin of the feet. Pulses were present but diminished bilaterally. Protective sensation to a 10 gram monofilament was absent. Vibratory sensation was absent along the heels. On VA examination in June 2011, the Veteran's history was reviewed. The Veteran complained primarily of a burning sensation in his feet. He also reported a constant tingling sensation and numbness in both feet. He stated that he could walk for two blocks and stand for 10 to 15 minutes. Physical examination revealed no appreciation of monofilament on the bilateral toes and in the plantar aspects of the soles of the feet. On the dorsal aspects of the feet, the Veteran could sometimes feel the monofilament and at other times, he indicated feeling it in a diminished manner. During pinprick testing the Veteran stated that he could not feel pinprick on his bilateral toes or the plantar aspects of his feet. On the dorsal aspects of his feet, he stated that he could sometimes feel the pinprick in a dull manner and at other times he could not feel it. Sensation above the ankle was normal. The examiner also noted that there were no ulcerations and that motor function was normal, including muscle tone, mass, and power. An additional VA examination was carried out in July 2012. The examiner indicated that the Veteran had mild intermittent pain, numbness, and parasthesias of the lower extremities. Strength of knee extension and flexion was normal. Strength of ankle plantar flexion and dorsiflexion was also normal. Deep tendon reflexes of the knees and ankles were decreased, at 1+. Light touch and monofilament testing was normal in the thighs, knees, lower legs, and ankles. It was decreased in the feet and toes. Vibration and cold sensation was decreased in the lower extremities. There was no muscle atrophy. The examiner noted that there were trophic changes in the form of shiny and somewhat thinned skin at the dorsum of both feet. He also noted that hair on the feet was absent. He concluded that the Veteran had mild incomplete paralysis of the sciatic nerve, and that the femoral nerves were normal bilaterally. During his March 2013 hearing, the Veteran testified that he sometimes had difficulty walking due to numbness in his feet. He indicated that he stumbled a couple of times per month. 38 C.F.R. § 4.124a, Diagnostic Code 8520, provides the rating criteria for paralysis of the sciatic nerve. Mild incomplete paralysis of the sciatic nerve warrants a 10 percent rating. A 20 percent rating requires moderate incomplete paralysis of the sciatic nerve. A 40 percent rating requires moderately severe incomplete paralysis of the sciatic nerve. A 60 percent rating requires severe incomplete paralysis with marked muscular atrophy. An 80 percent rating requires complete paralysis. When there is complete paralysis, the foot dangles and drops, no active movement of the muscles below the knee is possible, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § 4.124a. The term "incomplete paralysis" with peripheral nerve injuries indicates a degree of loss or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to the varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. See note at "Diseases of the Peripheral Nerves" in 38 C.F.R. § 4.124(a). Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated at a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123 (2012). The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Id. Upon careful review of the record, the Board concludes that a higher evaluation for peripheral neuropathy of the lower extremities is not warranted. In that regard, the most recent VA examination resulted in a finding that the Veteran had mild incomplete paralysis of the sciatic nerves bilaterally, and that the femoral nerves were normal. This July 2012 examiner indicated that strength was normal at the ankles and knees, and that sensory testing at the thighs, knees, lower legs and ankles was also normal. He stated that there was no muscle atrophy. These findings are essentially a reflection of previous examinations conducted in May 2010 and June 2011. Those examinations also note that the Veteran had no muscle atrophy, and that motor function was normal, including muscle tone, mass, and power. In summary, the Board finds that the criteria for higher 20 percent evaluations for peripheral neuropathy of the lower extremities have not been met. While sensory disturbance has been noted in each of three VA examinations, the most recent July 2012 examiner specified that the Veteran had mild incomplete paralysis of the sciatic nerve. The Veteran has described occasional functional impairment due to the peripheral neuropathy, in that he sometimes stumbles while walking. However, given the objective physical evidence, which includes only mild sensory findings, the Board finds that the current rating is adequate. As such, a 10 percent evaluation for each lower extremity is for application throughout the appeal. Extraschedular Consideration Ordinarily, the VA Rating Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012); see also Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a Veterans entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the level of disability and symptomatology and is found to be inadequate, the Board must then determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the initial inquiry posed by Thun, the Board has been unable to identify an exceptional or unusual disability picture with respect to the Veteran's service-connected diabetes and lower extremity peripheral neuropathy. The medical evidence fails to demonstrate, at any time during the appellate period, symptomatology of such an extent that application of the ratings schedule would not be appropriate. In fact, as discussed in detail above, the symptomatology of the Veteran's disabilities is specifically contemplated under the appropriate rating criteria. Accordingly, the Board finds that the Veteran's disability picture has been contemplated by the ratings schedule. Since the available schedular evaluation adequately contemplates the Veteran's level of disability and symptomatology, the second and third questions posed by Thun become moot. Even still, the record does not show that the Veteran has required hospitalization, or has lost significant periods of work, due to his diabetes mellitus or lower extremity peripheral neuropathy. In short, the evidence does not support the proposition that the Veteran's service connected disabilities present such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards and warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2012). ORDER Entitlement to an initial evaluation in excess of 20 percent for diabetes mellitus is denied. Entitlement to an initial evaluation in excess of 10 percent for peripheral neuropathy of the right lower extremity is denied. Entitlement to an initial evaluation in excess of 10 percent for peripheral neuropathy of the left lower extremity is denied. REMAND The Veteran seeks service connection for erectile dysfunction on the basis that it was caused or aggravated by his service-connected diabetes mellitus. Service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2012). This includes any increase in disability (aggravation) that is proximately due to or the result of a service-connected disease or injury. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either caused or aggravated by a service-connected disease or injury. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Private treatment records reflect that at the time new onset diabetes mellitus was identified in May 2008, the Veteran was already in receipt of medication for the treatment of erectile dysfunction. In that regard, the Board observes that Viagra is listed as a current medication as early as July 2007. On VA examination in July 2012, the examiner indicated that the etiology of the Veteran's erectile dysfunction was diabetes mellitus. He did not provide any rationale for this conclusion. Specifically, he did not provide a discussion of the Veteran's history, which shows that erectile dysfunction was noted prior to the diagnosis of diabetes mellitus. Because of this conflict, the Board finds that clarification must be sought. The Board notes that further development and adjudication of the Veteran's claim for erectile dysfunction may provide evidence in support of his claim for special monthly compensation. The Board has therefore concluded that it would be inappropriate at this juncture to enter a final determination on that issue. See Henderson v. West, 12 Vet. App. 11 (1998), citing Harris v. Derwinski, 1 Vet. App. 180 (1991), for the proposition that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any review of the decision on the other claim meaningless and a waste of appellate resources, the claims are inextricably intertwined. In light of the above discussion, the Board has determined that additional development is required. Accordingly, the case is REMANDED for the following action: 1. Schedule a VA examination by a physician with the requisite expertise to determine the etiology of the Veteran's erectile dysfunction. The claims folder should be forwarded to the examiner for review. The examiner should be directed to elicit a complete history from the Veteran. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion regarding whether it is at least as likely as not (i.e., probability of 50 percent) that erectile dysfunction is related to any disease or injury in service. The examiner should also provide an opinion regarding whether it is at least as likely as not (i.e., probability of 50 percent) that erectile dysfunction was caused or aggravated by the Veteran's service-connected diabetes mellitus. If aggravation is found, the examiner should address the following medical issues: (1) the baseline manifestations of the Veteran's erectile dysfunction found prior to aggravation; and (2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected diabetes mellitus. The examiner is advised that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. A discussion of the underlying reasons for all opinions expressed must be included in the examination report, to include reference to pertinent evidence where appropriate. If the examiner is unable to offer any of the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 2. The Veteran is hereby notified that it is his responsibility to report for any examination, and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655. 3. Upon completion of the examinations ordered above, review the examination report to ensure that it addresses the questions presented. Any inadequacies should be addressed prior to recertification to the Board. 4. Then, readjudicate the claim on appeal, with application of all appropriate laws, regulations, and case law, and consideration of any additional information obtained as a result of this remand. If the decision remains adverse to the Veteran, he and his representative should be furnished a supplemental statement of the case and afforded an appropriate period of time within which to respond thereto. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs